CMS SOM App. A, Tag A-0454

promptly by the ordering practitioner or by another practitioner who is responsible for the

care of the patient only if such a practitioner is acting in accordance with State law,

including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and

regulations.

Interpretive Guidelines §482.24(c)(2)

The hospital must ensure that all orders, including verbal orders, are dated, timed, and

authenticated promptly. The Merriam-Webster online dictionary defines “prompt” as performed

readily or immediately.

Verbal orders are orders for medications, treatments, interventions or other patient care that are

transmitted as oral, spoken communications between senders and receivers, delivered either face-to-face or via telephone.

The receiver of a verbal order must date, time, and sign the verbal order in accordance with

hospital policy. CMS expects hospital policies and procedures for verbal orders to include a

read-back and verification process.

The prescribing practitioner must verify, sign, date and time the order as soon as possible after

issuing the order, in accordance with hospital policy, and State and Federal requirements.

Authentication of a verbal order may be written, electronic, or faxed. The hospital must have a

method for establishing the identity of the practitioner who has given a verbal order, including

verification of the author of faxed verbal orders or computer entries.

In some instances, the ordering practitioner may not be able to authenticate his or her order,

including a verbal order (e.g., the ordering practitioner gives a verbal order which is written and

transcribed, and then is “off duty” for the weekend or an extended period of time). In such cases

it is acceptable for another practitioner who is responsible for the patient’s care to authenticate

the order, including a verbal order, of the ordering practitioner as long as it is permitted under

State law, hospital policies and medical staff bylaws, rules, and regulations. Hospitals may

choose in their policies to restrict which practitioners it would authorize to authenticate another

practitioner’s orders. For example, a hospital could choose to restrict authentication of orders for

pediatric patients to practitioners who are privileged to provide pediatric care. (77 FR 29053,

May 16, 2012)

• All practitioners responsible for the patient’s care are expected to have knowledge of the

patient’s hospital course, medical plan of care, condition, and current status.

• When a practitioner other than the ordering practitioner authenticates an order, that

practitioner assumes responsibility for the order as being complete, accurate and final.

• A qualified non-physician practitioner, such as a physician assistant (PA) or nurse

practitioner (NP), who is responsible for the care of the patient may authenticate a

physician’s or other qualified non-physician practitioner’s order only if the order is within

his/her scope of practice.

If State law requires that the ordering practitioner authenticate his/her own orders, or his/her own

verbal orders, then a practitioner other than the prescribing practitioner would not be permitted to

authenticate the verbal order in that State.

(71 FR 68682 and 77 FR 29053, May 16, 2012)

NOTE CONCERNING VERBAL ORDERS FOR LABORATORY TESTS:

The requirement to authenticate promptly a verbal order applies to verbal orders associated with

both inpatients and outpatients. It is possible that a hospital verbal order for a laboratory test

could be authenticated in compliance with the Clinical Laboratory Improvement Amendment

(CLIA) regulatory standard of authentication, i.e., within 30 days, but nonetheless be out of

compliance with the hospital Medical Records Services requirement for prompt authentication of

all orders, including verbal orders. Because CLIA laboratories – even if physically situated in a

hospital – are surveyed for compliance only with CLIA regulations, the laboratory would not be

cited for a deficiency by a CLIA survey team. However, hospital surveyors conducting a survey

would cite the hospital’s inpatient or outpatient recordkeeping for deficiencies under the Medical

Record Services CoP if the lab order originated for a patient during a hospital inpatient stay or

hospital outpatient clinic visit and the order was not authenticated promptly.

Survey Procedures §482.24(c)(2)

Does the hospital have policies and procedures requiring prompt authentication of all orders,

including verbal orders, by the ordering practitioner or, if permitted under State law, hospital

policy and medical staff bylaws, rules and regulations, another practitioner responsible for

the care of the patient?

• Do the hospital's policies and procedures for verbal orders include a "read back and

verify" process where the receiver of the order reads back the order to the ordering

practitioner to verify its accuracy?

Review orders, including verbal orders, in a sample of medical records. Have orders been

dated, timed, and authenticated promptly by the ordering practitioner or, if permitted under

State law, hospital policy and medical staff bylaws, rules and regulations, another

practitioner who is responsible for the care of the patient?

• Has the receiver of a verbal order dated, timed, and signed the order according to hospital

policy?