Signing and Dating of Verbal Orders
By Laura J. Rizzo, MHA, RHIA
Director, Health Information Management
The Commonwealth of Pennsylvania Department of Health (DOH) and, therefore the Joint Commission and Centers for Medicare and Medicaid Services (CMS) requires that all verbal orders be signed within twenty-four (24) hours. Quarterly compliance rates based upon our ongoing medical record review have confirmed that verbal order signing is an opportunity for improvement.
To ensure that we are in compliance with the regulation, please remember the following guidelines in regard to verbal orders:
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Verbal orders should only be given in emergency situations e.g. physician is scrubbed or the clinical situation precludes physician handwriting the order.
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Verbal and telephone orders need to be dated, timed, and signed as soon as possible.
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All members of a group may sign telephone/verbal orders of their partners or mid-level practitioners.
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Until the Commonwealth of Pennsylvania Department of Health changes its regulations to be in compliance with the vast majority of other states within our Union, we are held to a signature within 24 hours of the telephone/verbal order being given.
The nursing staff has been reminded to assist you in the identification of verbal orders for signature by tagging them with the red “please sign and date tags.” Please take the time when you are on the nursing unit to review the medical record for any unsigned verbal orders and sign and date them. Thank you for your time and effort in helping us to improve our compliance to achieve success on our next Joint Commission survey!
POA Indicator – Pressure Ulcers
By Michael Flood, M.D.
CMS has enacted guidelines regarding Present on Admission (POA) Indicators for acute care hospitals. CMS has identified high cost and/or high volume conditions that result in the assignment of a higher paying DRG. Starting in October 2008 Medicare will deny hospitals higher payment for the additional costs of treating these patients who acquire these conditions during their hospital stay. Of particular interest to the wound care community is the POA diagnosis of pressure ulcers.
The documentation of pressure ulcers is of particular concern at LGH. According to CMS guidelines physician documentation is required to qualify as a POA indicator. The nursing staff will be receiving special training regarding the documentation of pressure ulcers. They will assess all admitted patients for any skin breakdown and document accordingly. Nursing documentation will prompt the coding department to make an enquiry of the physician; however, physician documentation of pressure wounds is necessary for coding purposes.
By increasing awareness and by documenting appropriately the physician-nurse team will be able to impact the challenges of managing skin integrity by providing vital information about pressure wounds.