verbal and telephone orders 2011

Verbal and Telephone

Orders POLICY 6.07.13 Patient Care Verbal and Telephone Orders Issued: April 2001 Last Approval: May 2011

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Office of Origin: Office of the Chief Medical Officer

I. PURPOSE To specify when verbal and telephone orders may be used, how such orders are verified and the documentation of such orders. For the purpose of this policy, authorized providers include: Members of the Medical Staff and House Staff; dentists, podiatrists; nurse practitioners, and physician assistants or pharmacists who have been authorized to make verbal and telephone orders through standardized procedures and protocols/guidelines, respectively, as approved by the Medical Staff.

II. REFERENCES CMS Conditions of Participation

Joint Commission 2011 Comprehensive Accreditation Manual for Hospitals

Title 22, Section 70263. Pharmaceutical Service General Requirements.

California Business & Professions Code 2585-2586.8

UCSF Medical Staff Rules and Regulations, Section III, Physician Orders

Administrative Policy 6.07.06 Medical Orders

III. DEFINITIONS Verbal orders and telephone orders: Orders for medications, treatments, interventions or other patient care that are communicated as oral, spoken communications between an authorized provider and an authorized recipient.

IV. POLICY Verbal communication of orders should be limited to urgent situations where immediate written or electronic communication is not feasible.

V. PROCEDURES A. Receipt of Orders:

Verbal and telephone orders from authorized providers will be accepted and entered in the Physicians Order Sheet by designated staff members. The staff member taking the order shall record the order and read the order back to the authorized provider and request confirmation. Designated staff members include registered nurses, pharmacists, respiratory therapists, and registered dietitians. Verbal and telephone orders shall be accepted by these staff members as follows:

1. Registered Nurses may receive and record verbal and telephone orders from an authorized provider.

2. Pharmacists may receive and record verbal and telephone medication orders from an authorized provider.

3. Respiratory Therapists may receive and record verbal and telephone orders related to respiratory therapy from an authorized provider.



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4. Registered Dietitians may receive and record verbal and telephone orders related to p.o diet orders from an authorized provider.

B. Responsibility / Documentation

1. All verbal and telephone orders must be transcribed, dated, timed and signed by the authorized recipient in the patients medical record.

2. The authorized recipient must document that the transcribed verbal or telephone order was read back and confirmed to the authorized provider.

3. The authorized recipient may abbreviate read back and confirmed with the initials R&C.

4. Pharmacists, respiratory therapists and registered dietitians must notify the responsible registered nurse of any verbal or telephone orders they transcribe.

5. Verbal or telephone orders for restraints must be counter-signed as specified in the Medical Center Restraints policy.

6. Verbal and telephone orders must be counter-signed, dated and timed by the prescribing provider or an authorized provider within 48 hours. Countersignature by the prescribing physician is preferred. An authorized provider is defined as a provider responsible for the patients care at the time the therapy is given to the patient and/or at the time the order is counter-signed.

C. Monitoring and Compliance

1. Compliance with countersignature of verbal and telephone orders (full compliance defined as legibly or electonically signed, dated and timed within 48 hours) will be audited and reported to the Medical Record s Committee and included in the Chairs/Chiefs quarterly documentation report.

VI. RESPONSIBILITY Questions about the implementation of this policy should be directed to the Office of the Chief Medical Officer at 353-2760..

VII. RECENT HISTORY OF POLICY Approved November 2003 by Governance Advisory Council and Chancellor J. Michael Bishop

Revised January 2007 by Ernie Ring, Chief Medical Officer

Reviewed February 2007 by Policy Steering Committee and Strategic Leadership Council

Approved February 2007 by Executive Medical Board, Governance Advisory Council and Chancellor J. Michael Bishop



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Revised July 2007 by Jolene Carnagey, Regulatory Affairs, Paul Axelrod, Medical Center Administration and Lila Param, Childrens Hospital

Revised and reviewed August 2007 by Adrienne Green, MD, Marcia Canning, Ernie Ring, MD and Ann Williamson

Approved August 2007 by Executive Medical Board, Governance Advisory Council and Chancellor J. Michael Bishop

Revised October 2007 by Adrienne Green, MD, Associate Chief Medical Officer

Approved October 2007 by Executive Medical Board, Governance Advisory Council and Chancellor J. Michael Bishop

Revised May 2011 by Nutritional Services

Reviewed and Approved May 2011 Regulatory Affairs

Reviewed and Approved May 2011 Policy Steering Committee

Reviewed and Approved May 2011 Adrienne Green, Associate Chief Medical Officer

Reviewed and Approved May 2011 by Executive Medical Board, Governance Advisory Council and Chancellor Susan Desmond-Hellman, MD, MPH.

This guideline is intended for use by UCSF Medical Center staff and personnel and no representations or warranties are made for outside use. Not for outside production or publication without permission. Direct

inquiries to the Office of Origin or Medical Center Administration at (415) 353-2733.

verbal and telephone orders 2011

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