CMS SOM App. A, Tag A-0407

Interpretive Guidelines §482.23(c)(3)(i)

Verbal orders, if used, must be used infrequently. This means that the use of verbal orders must

not be a common practice. Verbal orders pose an increased risk of miscommunication that could

contribute to a medication or other error, resulting in a patient adverse event. 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. (71 FR 68679)

Hospitals are expected to develop appropriate policies and procedures that govern the use of

verbal orders and minimize their use, such as policies which:

• Describe situations in which verbal orders may be used as well as limitations or

prohibitions on their use;

• Provide a mechanism to establish the identity and authority of the practitioner issuing a

verbal order;

• List the elements required for inclusion in the verbal order process;

● Establish protocols for clear and effective communication and verification of verbal

orders.

The content of verbal orders must be clearly communicated. CMS expects nationally accepted

read-back verification practice to be implemented for every verbal order. (71 FR 68680) As

required by §482.24(b), all verbal orders must be promptly documented in the patient’s medical

record by the individual receiving the order.

Survey Procedures §482.23(c)(3)(i)

• Are there policies and procedures in place to minimize the use of verbal orders?

• Interview direct care staff to determine whether actual practice is consistent with verbal

order policies and procedures.

• Review both open and closed patient medical records for the use of verbal orders.

• Were the policies and procedures for the use of verbal orders followed?

• Does the number of verbal orders found in the sampled records suggest routine use,

which the regulations do not permit? The number of verbal orders is not in itself

evidence of noncompliance, but should result in more focused analysis. For example:

• Is there a pattern to the use of verbal orders? Some patterns might make sense – e.g.,

for orders entered between midnight and 7:00 a.m., it might be plausible that it was

impossible for the prescribing practitioner to write/computer-enter the order. On the

other hand, if one patient care unit has a high proportion of verbal orders, while

another does not, this might be a flag for inconsistent implementation of the hospital’s

policies and procedures for verbal orders.

• Are verbal orders used frequently for certain types of situations, and if so, is it

reasonable to assume that it is impossible or impractical for the prescribing

practitioners to write/enter the orders in such situations?

• Do certain practitioners use verbal orders frequently? From the limited number of

records sampled it may be difficult to detect trends related to specific practitioners,

but if a surveyor finds such evidence, further investigation is warranted to determine

if it is evidence of noncompliance.