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CentraCare Health – Monticello

  • Physician Orders Written-Verbal-Telephone

Policy Name:  Physician Orders Written-Verbal-Telephone

Date Reviewed: September 2017

Date Approved: 11/15/2017

Reviewed By: Medicine Medical Staff Committee

Approved By: Medical Executive Committee

Document Owner: MGR INPT SERVICES

 

PURPOSE

CentraCare Health-Monticello has adopted procedures to ensure that practitioner orders are appropriately and safely accepted and processed. 

 

POLICY

Orders for patient treatment will be consistently accepted, reviewed and processed using a method that ensures the treatment/medication order is received and processed accurately to reduce and avoid potential errors. Verbal orders are discouraged and will be accepted only under certain conditions.  This procedure applies to both medication and non-medication orders. 

 

DEFINITIONS

Medication:  Any substance, other than food or devices, that may be used on or administered to persons as an aid in the diagnosis, treatment, or prevention of disease or other abnormal condition.  This includes any product designated by the Food and Drug Administration as a drug, including vaccines, diagnostic and contrast agents, respiratory therapy treatments, total parenteral nutrition, sample medications, prescription medications and over-the-counter medications (i.e. herbal remedies, vitamins, blood derivatives, nutriceuticals and health supplements). 

Non-medication:  Includes enteral nutrition solutions, oxygen, and other treatment that do not necessitate the administration of a medication.

Written Order: Order, which is given by a practitioner credentialed for practice at CentraCare Health-Monticello that has been provided in written or electronic form and signed by the ordering individual at the time the order is written.

Verbal Order: Order, which is given by a practitioner credentialed for practice at CentraCare Health-Monticello that, has been given verbally with the physician present, but not signed at the time the order is given. The individual who received the order from the ordering practitioner writes or electronically enters this order. The order is subsequently signed by the practitioner.

Telephone Order: Order, which is given by a practitioner credentialed for practice at CentraCare Health-Monticello that, has been given via the telephone.  The individual who received the order from the ordering practitioner enters this order electronically.  The order is subsequently signed by the practitioner.

PROCEDURE

1)    OP orders are accepted from outside physicians/specialists who are licensed but not credentialed) All medication orders will include the following information:

a)    Drug name

b)    Dosage

c)    Route

d)    Frequency

e)    Purpose or indication for use for prn orders

f)     Special instructions

g)    Date, time and signature 

2)    Written Orders

a)    The ordering practitioner will enter orders in the appropriate patient’s electronic medical record.

3)    Telephone and Verbal Orders

a)    Verbal orders are discouraged and will be accepted only under emergency conditions such as a code blue, in the Operating Room, during a procedure or circumstances in which the patient condition is rapidly deteriorating requiring emergent intervention of treatment and/or medication administration or there is an emergent situation with another patient necessitating a verbal order.

b)    Telephone and verbal orders shall only be accepted by those individuals who may, within their scope of practice, administer or provide the treatment/medication ordered.

c)    All telephone and verbal orders shall be entered into the patient’s electronic medical record as they are received. If verbal orders are given in an emergent situation such as a code or during surgery, “repeat-back” is acceptable. Person receiving the verbal order will repeat-back the order for clarification.  "Repeat-back was accurate and verified by ordering.

d)    The telephone or verbal order shall be verified by verbally “reading the order back” clarifying dosage, route etc. The ordering individual shall confirm the order as “read back” is correct.

e)    The individual receiving the order will indicate in the electronic medical record the date and time the order was received as well as indicate the individual giving the verbal order.  The individual prescribing the treatment and/or medication or covering practitioner involved in the patient’s care shall electronically sign, date, and time the order within the time period addressed in the Medical Staff Rules and Regulations.

f)     All hand written orders will be reviewed for legibility and if determined to be legible, will write date, time, “checked by”, and sign name. If the order cannot be read, the patient’s nurse or another nurse to review the order for legibility.   If both individuals cannot read the order with certainty, the order will be considered “illegible” and the nurse will contact the physician to clarify the order.

g)    Any verbal admission order received by the provider should be signed as soon as possible.  EPIC requires admission order to be signed by provider prior to discharge.

 

REFERENCE

CentraCare Health - Monticello

1013 Hart Boulevard, Suite 1
Monticello, MN 55362
Phone: 763-295-2945
Business Office: 800-835-6618
Monticello Medical Group: 763-271-2200
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