Physician Orders and Verbal Orders
Makes sure every drug, device and treatment Agency staff give follows the physician’s written orders, sets who may take a verbal (oral) order and how it is read back, recorded and signed at once, and requires the physician’s countersignature within 14 days, which may not be longer than the 7 days 28 Pa. Code §601.31(d) allows. Covers documented follow-up of late countersignatures under the Department of Health survey guidelines, the Medical Assistance and Medicare countersignature rules, and faxed and electronic orders.
About this policy
- Policy number
- PA-HH-ORD-01
- Version
- 1.0
- Main rule
- 28 Pa. Code §601.31(d)
- Library
- Pennsylvania home health · 56 policies
- Category
- Clinical tasks
- Sections
- 20
In short
- Give care, medicines and treatments only as the physician has ordered.
- Only RNs, and therapists for their own discipline, may take a verbal order. LPNs and aides ask the physician to speak to an RN.
- Read every verbal order back to the physician, then record and sign it at once.
- The physician must countersign within 14 days, and never later than 7 days.
- Write down every attempt to get a late order signed, with the date, time and your signature.
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 (28 Pa. Code §601.31(d))
- 5. Who May Order Care
- 6. Who May Receive a Verbal Order
- 7. Receiving and Recording a Verbal Order
- 8. Countersignature Within the Time Frame
- 9. Medical Assistance and Medicare Rules
- 10. Questioning Orders
- 11. Carrying Out Orders
- 12. Written, Faxed, and Electronic 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
- Show me the verbal orders taken in the last month. Were they all countersigned within 7 days?
- This order was signed on day 12. Where is your documentation of the attempts to get it signed?
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