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Are Verbal Orders Prohibited?

Learning Objectives
1. Describe the myth or issue that impacts physicians and their care teams
2. Explain what existing regulatory policies indicate about the use of verbal orders
0.25 Credit CME
Abstract

Verbal orders are spoken orders given by a physician or other Licensed Independent Practitioner (LIP) to a person authorized to receive and record them in accordance with applicable policies, laws, and regulations. Most health care systems have their own policies concerning verbal orders, restricting or setting guidelines for their use. Patient quality and safety organizations have cautioned the practice of verbal orders due to concerns about risks they may introduce in some circumstances. Some physicians and health care systems have come to believe that verbal orders are not allowed due to federal health care policy and regulatory agency rules.

The Myth

The Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) prohibit verbal orders.

Verbal orders are spoken orders given by a physician or other Licensed Independent Practitioner (LIP) to a person authorized to receive and record them in accordance with applicable policies, laws, and regulations. Some physicians and health care systems have come to believe that verbal orders are not allowed due to federal health care policy and regulatory agency rules. Patient quality and safety organizations have cautioned against the practice of verbal orders due to concerns about risks they may introduce in some circumstances. Most health care systems have their own policies concerning verbal orders, restricting or setting guidelines for their use. Additionally, while state laws may limit if and how verbal orders may be used, CMS and TJC do not prohibit verbal orders.

Debunking the Myth

To our knowledge, there are no federal regulatory prohibitions on the use of verbal orders, though CMS regulations and guidance for hospitals are clear that CMS frowns upon verbal orders in the medication context. While CMS regulations and TJC standards do identify recommendations for the use of verbal orders, there are relatively few regulatory requirements specific to their use.

Physicians in Medicare-participating hospitals can use verbal orders as well as pre-printed and electronic standing orders, order sets, and protocols. Verbal orders may be enacted immediately by individuals who are administering care within the scope of their licensure, certification, or credentialing.1 There are no CMS limitations on the use of verbal orders in the community (ambulatory care) setting.

Regulatory Clarification

  1. According to CMS, verbal orders must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient. That practitioner must be acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. The receiver of a verbal order must date, time, and sign the verbal order in accordance with hospital or clinic policy.2

  2. In January 2007, CMS added a provision to the Nursing and Medical Records Condition of Participation requiring for the next 5 years that all orders including verbal orders be dated, timed, and authenticated within 48 hours.3 This CMS policy was temporary, and lapsed in January 2012 when the 48-hour requirement for authentication of verbal orders was eliminated.4

  3. The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders. Documentation assistants who are not authorized to submit orders should leave the order as pending for a certified or licensed personnel to activate or submit the orders after verification. Transcribing orders into the EHR while providing documentation assistance is not considered a verbal order. Verbal orders are different because they are expected to be acted upon immediately by individuals who are practicing within the scope of their licensure, certification, or practice in accordance with law and regulation as well as with organizational policy.1,5

  4. TJC standards do not specify the time frame for authentication of documentation. Organizations are free to determine the time frame for completion of authentication, however, the timeframe must comply with any applicable state or local laws or regulations.6

  5. TJC standards provide that all types of personnel performing documentation assistance, both in ambulatory and hospital settings, may, at the direction of a physician or another LIP, enter orders into an EHR.1,5 An LIP must authenticate the verbal order as soon as practical, verifying it with their dated and timed signature. This authentication may be performed by the ordering practitioner, or by another practitioner involved in the care of the patient.

  6. In general, federal regulations and accreditation agency standards do not require authentication of verbal orders within a specific time frame. These requirements are usually in state licensure regulations. Therefore, it is important to be familiar with any pertinent state-specific laws and regulations to ensure full compliance.

Resources

CMS §482.23(c)(3)(i) - Page 42: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R95SOMA.pdf

AMA Team-Based Care STEPS Forward Toolkit: https://edhub.ama-assn.org/steps-forward/module/2702513

AMA Pre-visit Laboratory Testing STEPS Forward Toolkit: https://edhub.ama-assn.org/steps-forward/module/2702697

AMA Creating the Organizational Foundation for Joy in Medicine™ STEPS Forward Toolkit: https://edhub.ama-assn.org/steps-forward/module/2702510

AMA STEPS Forward™ Saving Time Playbook for physicians: 3 strategies: https://www.ama-assn.org/practice-management/sustainability/ama-steps-forward-saving-time-playbook-physicians-3-strategies#strategy-one-stop-doing-unnecessary-work

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The AMA Debunking Medical Practice Regulatory Myths series provides physicians and their care teams with regulatory clarification to streamline clinical workflow processes and improve patient outcomes. Learn more

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.25 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.25 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.25 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;

0.25 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and

0.25 CME points in the American Board of Surgery’s (ABS) Continuing Certification program.

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

References:
1.
The Joint Commission.  Ambulatory FAQs.  Documentation Assistance Provided By Scribes. 2021. https://www.jointcommission.org/standards/standard-faqs/ambulatory/record-of-care-treatment-and-services-rc/000002210/Google Scholar
2.
United States Title 42 Chapter IV Subchapter G Part 482 Subpart C. 482.24 (c)(2). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C#p-482.24(c)(2))
3.
Centers for Medicare & Medicaid Services Proposed Rule.  Medicare and Medicaid Programs; Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Orders; Securing Medications; and Postanesthesia Evaluations. 2005https://www.federalregister.gov/documents/2005/03/25/05-5916/medicare-and-medicaid-programs-hospital-conditions-of-participation-requirements-for-history-and
4.
Centers for Medicare & Medicaid Services Final Rule.  Medicare and Medicaid Programs Reform of Hospital and Critical Access Hospital Conditions of Participation. https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Downloads/CMS-3244-F.pdf
5.
The Joint Commission.  Hospital and Hospital Clinics FAQs.  Documentation Assistance Provided by Scribes. 2021. https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/record-of-care-treatment-and-services-rc/000002210/Google Scholar
6.
The Joint Commission.  Standards FAQs Medical Record Authentication Time Frame. 2021. https://www.jointcommission.org/standards/standard-faqs/ambulatory/record-of-care-treatment-and-services-rc/000001691/
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