Early in my regulatory career, I worked at a hospital that was cited by CMS for excessive use of verbal (in person) orders. As part of our corrective action plan, we essentially informed the medical staff that such orders would no longer be accepted unless it was an emergency or issued during a procedure. One physician – who had a history of passive / aggressive behavior – simply rounded on his patients, left the care unit, went to a different one, and phoned his orders in. Sigh… such are the challenges we face. I’m sure you can relate.

There are legitimate reasons to minimize the use of verbal orders. Mistakes can be made and lead to errors in care. So what does CMS expect? The interpretive guidance in Appendix A of the State Operations Manual under §482.23(c)(3)(i) and §482.24(c)(2) forms the basis for this discussion.

WHAT IS A VERBAL ORDER
Verbal orders are orders for medications, treatments, interventions or other patient care that are transmitted as oral, spoken communications between senders and receivers, delivered either face-to-face or via telephone.

HOW FREQUENTLY CAN A HOSPITAL USE VERBAL ORDERS?
Verbal orders, if used, must be used infrequently. This means that the use of verbal orders must not be a common practice. Verbal orders should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to write the order or enter it into an electronic prescribing system without delaying treatment. Verbal orders are not to be used for the convenience of the ordering practitioner (despite what my passive / aggressive physician thought.) While both telephone and in-person verbal orders are covered by this expectation, CMS – and accrediting agencies – focus on in-person rather than telephone orders.

POLICY REQUIREMENTS
Your hospital must develop appropriate policies and procedures that govern the use of verbal orders and minimize their use. The policies must address:

• Situations in which verbal orders may be used as well as limitations or prohibitions on their use;
• Mechanisms to establish the identity and authority of the practitioner issuing a verbal order;
• Elements required for inclusion in the verbal order process;
• Protocols for clear and effective communication and verification of verbal orders.

DATING / TIMING / AUTHENTICATION
Your hospital must ensure that all orders, including verbal orders, are dated, timed, and authenticated promptly. The Merriam-Webster online dictionary – referenced by CMS – defines “prompt” as performed readily or immediately. This addresses entering the verbal order into the patient’s record, not the co-signing by the ordering practitioner.

The receiver of a verbal order 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.

The ordering practitioner must verify, sign, date and time the order as soon as possible after issuing the order, in accordance with hospital policy, and State and Federal requirements. Absent State law, CMS and accreditors allow the hospital to define what “as soon as possible” means.

In some instances, the ordering practitioner may not be able to authenticate his or her order, including a verbal order. In such cases it is acceptable for another practitioner 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 policies and medical staff bylaws, rules, and regulations.

NOTE CONCERNING VERBAL ORDERS FOR LABORATORY TESTS:
The requirement to promptly authenticate a verbal order applies to both inpatients and outpatients. It is possible that a verbal order for a laboratory test could be authenticated in compliance with the Clinical Laboratory Improvement Amendment (CLIA) regulatory standard of authentication, i.e., within 30 days, but be out of compliance with the hospital Medical Records Services requirement for prompt authentication of all orders, including verbal orders.

Because CLIA laboratories – even if physically situated in a hospital – are surveyed for compliance only with CLIA regulations, the laboratory would not be cited for a deficiency by a CLIA survey team. However, hospital surveyors would cite deficiencies under the Medical Record Services CoP if the lab order originated for a patient during a hospital inpatient stay or hospital outpatient clinic visit and the order was not authenticated promptly.

Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.

Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.

Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.