Verbal Orders and the Final Word

Verbal Orders and the Final Word

If you have been wishing for clarification on the timeframes for verbal order authentication, your wish has been answered! Finally, we are able to bring you the final answer, straight from the Centers for Medicare and Medicaid Services (CMS).

In the new CMS Interpretive Guidelines released in April 2008, for hospitals, Tag A-0457 states:

“482.24(c)(1)(iii) All verbal orders must be authenticated based upon Federal and State law. If there is no State law that designates a specific timeframe for the authentication of verbal orders, verbal orders must be authenticated within 48 hours.”

This statement has created a buzz in some states, as state requirements have a variety of expectations, from authentication within 24 hours to requirements that all verbal orders be authenticated when the medical record is completed, implying within 30 days of discharge.

In a recent conversation with David Eddinger, Technical Director Hospital Survey and Certification, CMS – Division of Acute Care Services, based in Baltimore, MD, the following principles were outlined:

  • If the State laws specifically designate a timeframe (i.e., 5 or 7 days) for the authentication of ALL verbal orders, the State timeframe will be followed, even if it exceeds the Federal 48 hours.
  • If the State laws specifically designate a timeframe (i.e., 5 or 7 days) for the authentication of some, but not all verbal orders (i.e., all no code orders or medication orders), the Federal timeframe will be followed, even if it is shorter than the State timeframe.
  • If the State laws specifically designate a timeframe (i.e., 5 or 7 days) for the authentication of orders, not stipulating verbal orders, the Federal timeframe will be followed, even if it is shorter than the timeframe set by State law.
  • Timeframes for completion of the entire medical record (such as within 30 days) are not specific enough for application to verbal orders. Thus, the Federal law would apply.
    • Establish clear expectations for the Medical Staff in the bylaws, rules, and regulations.
    • Monitor and analyze the reasons for verbal and telephone order use, and take steps to minimize their use (MM.3.20).
    • Consider analyzing orders for time of day, urgency, or classification (treatment, drug classification) to discover ways to minimize the need for verbal and telephone orders.
    • Train case managers and unit nurses to predict the needs of patients so orders can be obtained during physician visits to minimize the need for after hour calls and non-emergent telephone orders.
    • For organizations utilizing paper medication orders, does the organization use flags or reminders to assist in the quick identification of verbal orders, perhaps using color-coded flags for specific disciplines?
    • For hospitals with CPOE, does the system default to a screen that reminds physicians to authenticate verbal orders prior to moving to other activities following log-in? Have “hard-stops” been placed to prohibit them from moving on to other screens prior to authenticating verbal orders? Has a screen been put in place to record why the physician chooses to proceed to other activities prior to authentication of verbal orders, so that valid reasons (code blue) and less patient-focused reasons (running late) can be tracked, trended, analyzed and reported?
    • Does the hospital gather physician-specific data so that comparative data can be shared? Has verbal order authentication been considered as an element of the ongoing professional practice review (OPPR)?

    • As Goes CMS, so Goes Joint Commission

    The Joint Commission standards are largely silent on the expectations for the authentication of verbal orders. IM.6.10 EP 4 states, “Medical record entries are dated, the author identified and, when necessary according to law or regulation or hospital policy, authenticated, either by written signature, electronic signature, or computer key or rubber stamp.” Similarly, in 2009, RC.02.03.07 will default to law and regulation for expactations regarding authentication of verbal orders. This places the burden on organizations to know and understand the expectations for verbal order authentication and take steps to assure compliance to avoid findings during Joint Commission and CMS surveys.

    Achieving and Maintaining Compliance

    Ultimately, verbal order authentication compliance belongs squarely in the hands of the Medical Staff and its leaders. However, this does not mean that other professionals do not have a role in assisting with compliance. Consider whether your organization has done all it can to assist in achieving compliance with verbal order authentication compliance through the following mechanisms:

    Finding Resources

    Most hospitals are finding that surveys are tougher than in the past. Both The Joint Commission and CMS have been under pressure to raise the bar for hospital performance, Surveyors have been trained not to focus on validating compliance, but to seek evidence of non-compliance. The subtle difference has increased the burden on hospitals.

    If you are looking for resources for ongoing preparation for Joint Commission and CMS compliance, consider the services of Compass Group. We are able to help your organization meet the expectations of both regulatory bodies by providing answers and guidance with attention to the unique requirements of each regulator. Sharing examples and best practices from around the country, Compass Group moves beyond providing standards interpretation assistance by recommending realistic solutions. The Compass Forum audio conference series provides updates on each set of standards each year. Mock surveys and focused consultations provide assistance by assessing compliance and recommending solutions, with each visit customized to the organization’s needs.