Myth or fact? Verbal orders are prohibited in health care

Some doctors and health systems operate on the assumption that federal health policy and regulatory agency rules prohibit them from giving verbal orders. However, to the best of the AMA’s knowledge, the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission do not prohibit the use of verbal orders.

The AMA is spreading that message as part of a series of “Debunking Regulatory Myths” articles that provide clarification to physicians and their care teams in an effort to reduce the administrative burden that distracts physicians’ attention away from patient care.

“Doctors in hospitals participating in Medicare can use verbal orders, standing orders, order sets and pre-printed and electronic protocols. Verbal orders can be issued immediately by individuals who are administering assistance under their license, certification or credentials, “the myth article,” Are verbal orders prohibited? “Says.” There are no CMS restrictions on ‘use of verbal orders in the community setting (outpatient care). “

Related coverage

Myth or fact? Support personnel must log out of the EHR in the documentation

While federal agencies cannot expressly prohibit voice orders that a physician or other licensed practitioner (LIP) can give to appropriate colleagues, most health systems have policies that limit or set guidelines for verbal orders.

Some state laws may also restrict these voice orders, and patient quality and safety organizations have warned about the practice because of the risks they can introduce in some situations, notes the Debunking Regulatory Myths article.

Although CMS does not expressly prohibit the use of verbal orders, the agency’s regulations and guidelines for hospitals are clear: Verbal orders in the context of drugs are frowned upon, the article states.

Other things the AMA has found that doctors should keep in mind when dealing with verbal orders based on the CMS and Joint Commission rules, include:

  • Verbal orders must be dated, timed, and timely authenticated by the ordering physician or other physician responsible for patient care, CMS says.
  • Professionals must act in accordance with state law, including the scope of practice laws, hospital policies and the medical staff statute, rules and regulations.
  • The authorized documentation assistant is encouraged to repeat the verbal order, especially for new drug orders.
  • There is no specified time frame for authenticating documentation to Joint Commission standards, so organizations can determine a time frame that is compliant with applicable state or local laws or regulations.
  • Anyone providing documentation assistance in an outpatient or inpatient setting can, on the recommendation of a physician or LIP, place orders in the EHR, the Joint Commission standards state.
  • Federal regulations and accreditation agency standards do not require verbal order authentication within a specific time frame. Instead, their requirements are usually part of the state licensing regulation.

Related coverage

Myth or fact? Teaching doctors must re-document the work of EHR students

The AMA’s set of regulatory myths debunked is part of AMA’s practice transformation efforts and provides physicians and their care teams with resources to reduce the guesswork and administrative burden so their attention can be focused on streamlining clinical workflow processes, improving patient outcomes and increasing physician satisfaction.

This series includes a web page dedicated to each regulatory myth, such as the one that support personnel must log out of an EHR in between documentation. In these articles, the myth is established and debunked, and resources are provided to remove any lingering doubts that the myth is not true. More articles are added regularly.

Previous myths explored include whether:

Physicians and members of their care team are encouraged to ask their questions about misinterpreted regulations that could take their time away from patients. Email the Case Transformation Team directly to [email protected].

Leave a Comment

Your email address will not be published.