Physician and Practitioner Orders, Verbal Orders, and Countersignature
Requires every drug, treatment and service to be given only on the order of a physician or other authorized practitioner; sets who may take a verbal order, how it is read back, recorded, signed, dated and timed; requires countersignature within the Agency’s time frame of 14 days, never more than the 60 days North Carolina allows and always before a Medicare claim is billed; and sets how orders are tracked, clarified and kept.
About this policy
- Policy number
- NC-HH-ORD-01
- Version
- 1.0
- Main rule
- 10A NCAC 13J .1302
- Library
- North Carolina home health · 57 policies
- Category
- Clinical tasks
- Sections
- 20
In short
- We give drugs, treatments and services only as a physician or other authorized practitioner has ordered.
- Only registered nurses, licensed practical nurses (for drugs and treatments) and therapists (for their own discipline) may take a verbal order.
- Write the order down, read it back, and record the date, the time and your signature.
- Get every verbal order signed by the practitioner within 14 days, never more than 60 days, and before Medicare is billed.
- If an order is unclear, unsafe or conflicts with another order, do not carry it out until the practitioner clarifies it.
What's inside
20 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (10A NCAC 13J .1302; 42 CFR §484.60(b))
- 5. Who May Give an Order
- 6. Written Orders
- 7. Who May Take a Verbal Order
- 8. Taking and Recording a Verbal Order
- 9. Getting Verbal Orders Signed
- 10. Orders From More Than One Practitioner, and Questioning Orders
- 11. Orders for In-Home Aide Services and Supplies
- 12. Keeping Orders
- 13. Responsibilities
- 14. Records and Compliance Monitoring
- 15. Staff Training
- 16. References
- 17. Related Policies and Forms
- 18. Approval
- 19. Revision History
An inspector may ask
- Who in your agency may take a verbal order? Show me where that is written.
- Show me this verbal order: who took it, when, and when the physician signed it.
See Cura Core with your agency's name on it.
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