KADLEC MEDICAL CENTER
HOUSE-WIDE
Section: Corporate Compliance
POLICY AND PROCEDURES
TITLE: Physician Orders for Outpatient Services
ADMINISTRATIVE
APPROVAL: Rand Wortman 09/18/2003
COMMITTEE APPROVAL/REVIEW:
POLICY: X
PROCEDURE:
GUIDELINE:
STANDARD:
NO. 1569
EFFECTIVE DATE: 09/18/2003
PAGE 1 OF 2
SUPERSEDES: New
Compliance Committee,
DEVELOPMENT TEAM/AUTHOR(S): Jennie Martin, Terry Long,
AUDIT REVIEW: (By and Date)
Purpose: To ensure appropriate diagnostic studies and therapeutic services are provided to patients referred to Kadlec by
authorized licensed practitioners.
Policy:
Outpatient diagnostic studies and therapeutic services may be provided only in accordance with an order written by an
appropriately licensed practitioner. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be
ordered by the physician/practitioner who is treating the beneficiary, that is, the physician who furnishes a consultation or
treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific
medical problem.
Mammography exception. Radiologists who interpret screening mammographies are allowed to order and interpret
additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the
screening exam.
All orders must include the following five elements:

Date of order

Patient name

Test or service being ordered

Diagnosis or reason for service

Physician (or other licensed practitioner) signature
Date of Order – If the written order is presented without the date completed, the clerk may verify the date with
the physician’s office and fill in the information as indicated.
Patient Name – Patient name should be complete. If the patient name is incomplete or misspelled the clerk may
complete or correct per patient indication.
Test or Service being ordered - Orders shall be specific and complete. The staff of the hospital has the right and
the obligation to question any order that is illegible, ambiguous or incomplete.
Diagnosis or reason for test - Referring physicians are required to provide diagnostic information to the hospital
at the time the test is ordered. Diagnosis or reason for service should not include the following terms: probable,
suspected, questionable, or rule out. If diagnosis is not yet determined, signs or symptoms should be used. If an
order for service includes these terms, hospital personal will contact the ordering physician for clarification. If the
written order is presented without the reason or diagnosis completed, the clerk may verify the information with the
physician’s office and fill in the information as indicated.
KADLEC MEDICAL CENTER
POLICIES & PROCEDURES
TITLE: Physician Orders for Outpatient Services
DATE:
NO.
1569
Page 2 of 2
Physician Signature- Kadlec requires physician signature to authenticate all orders for outpatient diagnostic or
therapeutic services. Upon request, this requirement may be waived for electronically generated orders if it is
determined by the hospital that appropriate security measures are in place.
Verbal or telephone orders are those given orally by a physician to a licensed health care professional. Registered and
licensed Practical Nurses may take verbal or telephone orders related to all aspects of patient care. In outpatient
departments, verbal orders shall be considered to be in writing if dictated to licensed staff functioning within their area of
expertise. Verbal and telephone orders should be used infrequently and at the discretion of the department director.
In departments that allow verbal orders the following procedures must be followed: These orders shall always be read back
to the originator to verify accuracy. The five required elements of an order must be complete. The receiver’s full name and
title shall follow the transcribed order. The responsible physician or covering physician shall authenticate verbal orders
within 30 days. Designated department representative will be responsible for obtaining the physician’s signature to
authenticate the order. If authentication is not received in 30 days (or as defined in Medical Staff Rules and Regulations) a
copy of the order will be forwarded to the Director of HIM for follow-up and possible physician sanctions.
Revision or Clarification of Order
If the ordering physician submits an order that includes unclear or incorrect information, hospital staff is obligated to
question the ordering physician and to revise the order as directed by the physician. (i.e. correction to diagnosis or date)
Documentation to alter the order must be maintained with the original order. The documentation may be written
information from the ordering physician or a written note documenting the telephone call with the ordering physician. A
faxed copy of the documentation is acceptable.
Mammography Exception:
Self-Referred Screening Mammogram - Screening mammography is a radiological procedure furnished to a woman
without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician's
interpretation of the results of the procedure. Medicare allows for self-referred screening mammograms based on age and
frequency requirements. Patients presenting for self-referred screening mammograms will be requested to provide a
personal physician name for results but no order is required. This requirement also applies to Kadlec employee screening
mammograms.
Outpatient Rehab Exception:
Speech Therapy, Massage Therapy and Physical Therapy may be self-referred under Washington State Law. Kadlec
accepts self referrals for these services.
WAC 246-320-385 Outpatient Care Services
WAC 246-320-205 Management of Information
42 CFR Conditions of Participation for Hospitals §482.24(c)(1) Medical Record Services
42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions
42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests (a)(2) Mammography
Balanced Budget Act §4317(b)
21 CFR 900 Subsection B (2)
CMS HIM 10 §451(G)
JCHO FAQ’s Authentication of Documentation
Kadlec Medical Center, Medical Staff Rules and Regulations §(2)