Practitioner Orders and Verbal Orders
Sets out who may order care for Agency patients, the kinds of orders the Agency accepts, who may accept a verbal order (registered nurses, and therapists for their own discipline), how a verbal order is read back, documented, signed, dated and timed and recorded in the plan of care, how it is sent to the practitioner for authentication and dating within the Agency’s own time frame of 14 days, how unsigned orders are tracked, and the Medicare and Ohio Medicaid rule that signed orders must be in the record before the Agency bills.
About this policy
- Policy number
- OH-HH-ORD-01
- Version
- 1.0
- Main rule
- 42 CFR §484.60(b)
- Library
- Ohio home health · 59 policies
- Category
- Clinical tasks
- Sections
- 21
In short
- Give care only as ordered by a physician or allowed practitioner and written in the plan of care.
- Only RNs, and therapists for their own discipline, may take a verbal order. LPNs connect the caller with an RN.
- Read every verbal order back, then sign, date and time it and record it in the plan of care.
- The practitioner must sign verbal orders within 14 days. The office tracks unsigned orders.
- If an order is unclear or unsafe, do not carry it out. Call the practitioner and the clinical manager.
What's inside
21 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §484.60(b))
- 5. Who May Order Care
- 6. Kinds of Orders
- 7. Who May Accept a Verbal Order
- 8. Receiving and Recording a Verbal Order
- 9. Sending the Order for Authentication
- 10. Tracking Unsigned Orders
- 11. Signed Orders Before Billing
- 12. Written, Faxed, and Electronic Orders
- 13. Carrying Out and Clarifying Orders
- 14. Responsibilities
- 15. Records and Compliance Monitoring
- 16. Staff Training
- 17. References
- 18. Related Policies and Forms
- 19. Approval
- 20. Revision History
An inspector may ask
- Who in your agency may take a verbal order from a practitioner?
- Show me a verbal order: who received it, when, and when the practitioner signed it.
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