CMS SOM App. A, Tag A-0408

are authorized to do so by hospital policy and procedures consistent with Federal and State

law.

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

A verbal order for drugs and biologicals may only be accepted by an individual who is permitted

by Federal and State law and hospital policy to accept verbal orders. Consistent with the

requirements of §482.24(b), the person who received the verbal order must promptly document it

in the medical record.

Survey Procedures §482.23(c)(3)(ii)

• Determine whether the hospital has policies and procedures, consistent with Federal and

State law, governing who is authorized to accept verbal orders.

• Review open and closed patient medical records containing verbal orders for drugs and

biologicals. Determine whether the orders were accepted and documented by authorized

hospital personnel.

• Interview several direct care staff to determine if they are permitted to take verbal orders

for drugs and biologicals, and determine whether such staff have been authorized to do so

in accordance with hospital policy.