CMS SOM App. L, Tag Q-0184

(3) Orders given orally for drugs and biologicals must be followed by a written

order and signed by the prescribing physician.

Interpretive Guidelines: §416.48(a)(3)

Orders for drugs and biologicals that are transmitted as oral, spoken communications

between the prescribing physician and the ASC’s nursing staff, delivered either face-to-face or via telephone, commonly called “verbal orders,” must be followed by a written

order that is signed by the prescribing physician.

CMS expects ASC policies and procedures for verbal orders to include a read-back and

verification process whereby the nurse receiving the order repeats it back to the

prescribing physician, who verifies that it is correct. When administering a drug or

biological per a verbal order, the nurse should include in the medical record entry

covering the administration of the drug or biological a note that it was prescribed orally,

indicating the name of the prescribing physician.

The prescribing physician must sign, date, and time the written order in the patient’s

medical record confirming the verbal order. This should be done as soon as possible after

the verbal order is issued.

In the ASC setting medications prescribed for patients in recovery present a particular

area of vulnerability in terms of the potential failure to follow-up a verbal order with a

written order signed by the prescribing physician. Careful attention must be given to

compliance with the regulatory requirement for medications administered during

recovery room.

Survey Procedures: §416.48(a)(3)

• Does the ASC have policies and procedures addressing verbal orders? Does it

require the prescribing practitioner to sign, date, and time a written order as soon

as possible after issuing the verbal order?

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

verify" process where the nurse who receives the order repeats it back to the

prescribing physician to verify that the order was understood accurately?

• Ask ASC nursing staff how they handle verbal orders. Does their practice

conform to the regulatory requirements? Do they use a read-back and verify

process?

• Is there evidence in the medical records reviewed that each verbal order was

followed by a written order signed by the prescribing physician?