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TOPIC:

 

Verbal and Telephone Orders

PURPOSE:

 

To establish guidelines for Residency Programs regarding resident/fellow use and authentication of verbal and telephone orders.

POLICY:

 

The use and authentication of verbal orders by residents/fellows will comply with the Center for Medicare and Medicaid Service's Conditions of Participation, AIMMC Medical Staff By-Laws and the Department of Health Information Management policies and procedures.

Procedure

  1. Verbal orders are to be limited to circumstances in which hands-on patient care prevents the ordering resident/fellow from entering an order into Care Connection/CPOE.
  2. Verbal orders must be authenticated (signed) before the resident/fellow leaves the patient care area.
  3. Residents/fellows are expected if at all possible to enter all patient care orders into the electronic medical record per Care Connection/CPOE.
  4. Telephone orders are to be used infrequently and only as necessary.
  5. Telephone orders must be authenticated within 48 hours. Telephone orders are available for signature electronically via Care Connection/Profile/Provision.
  6. A monthly report detailing resident/fellow compliance regarding the authentication of verbal and telephone orders will be distributed to all Program Directors.
  7. Each Program will establish and enforce its own verbal and telephone order policy, consistent with institutional policy, to insure resident/fellow compliance.

Approved by Education and Research Committee 06/06/07

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