Awareness : Newsletter Articles

Authenticating Orders

A hospital must make sure that all orders, including verbal orders, are dated, timed and authenticated promptly. Verbal orders are orders for medications, treatments, interventions or other care that are transmitted as oral, spoken communications between senders and receivers, delivered either face-to-face or via telephone. The receiver of the verbal orders must date, time, and sign the verbal order in accordance with hospital policy. CMS expects hospital policies and procedures for verbal orders to include a read-back and verification process.

Authenticating of a verbal order may be written, electronic, or faxed. The hospital must have a method for establishing the identity of the practitioner who has given a verbal order, including verification of the author of faxed verbal orders or computer entries.

In some instances, the ordering practitioner may not be able to authenticate his or her order, including a verbal order (e.g., the ordering practitioner gives a verbal order which is written and transcribed, and then is “off duty” for the weekend or an extended period of time). In such cases it is acceptable for another who is responsible for the patient’s care to authenticate the order, including a verbal order, of the ordering practitioner as long as it is permitted under State law, hospital hospital policies and medical staff by laws, rules, and regulations. Hospitals may choose in their policies to restrict which practitioners it would authorize to authenticate another practitioner’s order. Below are three guidelines which are imperative to follow when creating an ordering plan.

  • All practitioners responsible for the patient’s care are expected to have knowledge of the patient’s hospital course, medical plan of care, condition and current status.
  • When a practitioner other than the ordering practitioner authenticates an order, that practitioner assumes responsibility for the order as being complete, accurate and final.
  • A qualified non-physician practitioner, such as physician assistant (PA) or nurse practitioner (NP), who is responsible for the care of the patient may authenticate a physician’s order or other qualified non-physician practitioner’s order only if the order is within his/her scope of practice.