PATIENT CARE SERVICES
POLICY & PROCEDURE
Title: Orders for Medical Treatment
Section: Provision of Care, Treatment, & Services
Dept of Origin: Patient Care Services &
Pharmacy Department
Effective Date: June 26, 2003
Last Review / Revision Date: 7/2/2012
Network CMO Signature: Donald Denmark
CNO Signature: Deb Finch CSJ, Martha
Gerganoff CSM, Deb Knapheide CHCH, Sue Gold
CHVI
I. POLICY STATEMENT
• Only authorized individuals that have been granted clinical privileges by Carondelet Health
Network (CHN) may write orders for medical treatment including medication orders. In the case of
non-physicians (Allied Health Professionals), prescribing/administration privileges depend on
licensure and privileges granted by the professional staff, and on Arizona State regulations.
• Consulting physicians without professional staff privileges at CHN are not permitted to write/ give
orders or administer medication.
• Orders for treatment including medication orders are carried out by appropriately licensed
associates. Treatment orders may be delegated to non licensed associates within their scope of
practice.
• It is not acceptable for physicians or licensed independent practitioners to text orders for patients to
the hospital or other healthcare setting. This method provides no ability to verify the identity of the
person sending the text and there is no way to keep the original message as validation of what is
entered into the medical record.
• Medical, nursing, and other applicable professional staff will be educated on the conditions and
criteria for the use of nurse initiated orders and the individual responsibilities associated with their
initiation and execution.
II. PURPOSE
This policy establishes guidelines for the management of orders for medical treatment at CHN
facilities.
III. DEFINITIONS
Pre-Printed Orders: selected medical directives to be implemented in specific patient care situations.
Requires an order from a licensed Independent Practitioner to initiate.
Pre- Printed Orders and protocols are designed through an interdisciplinary process involving
physicians, clinicians and ancillary personnel with a vested interested in the process and delivery of
patient care for which they are intended.
Telephone Orders: Medical patient care directives dictated over the phone to a licensed associate
when the Licensed Independent Practitioner is not physically present.
Verbal Orders: Oral medical patient care directives taken when the physician is physically present but
is unable to write orders.
Acknowledgement: The physician’s agreement that the initiation of the order set is appropriate for a
specific patient. Acknowledgement may occur via telephone, or in person, and is treated as a telephone
order or verbal order.
Authentication: The date, time and legal signature of the ordering physician
Orders for Medical Treatment
Page 1 of 8
Nurse Initiated Orders: An order set that may be implemented by an RN prior to obtaining the order
from the physician that is responsible for the care of the patient. The conditions for initiation by a
nurse are as follows:
• if the timing of obtaining the order to initiate would be a barrier to effective emergency
response
• if the timing of obtaining the order to initiate would be a barrier to timely and necessary care
• if the timing of obtaining the order to initiate would be a barrier to other patient safety
advances.
Nurse initiated orders are approved for use in the Emergency Center, Labor and Delivery, and Wound
Care Departments. They are developed through an interdisciplinary process involving physicians,
clinicians and ancillary personnel with a vested interest in the process and delivery of patient care for
which they are intended. Approval by the Medical Executive Committee and Chief Nursing Officer
Council is required. Approval by Pharmacy and Therapeutics committee is only required if medications
are involved.
The Registered Nurse initiating the order must sign, time, and date the Pre printed order or protocol at
the time of initiation, and must notify the physician and receive acknowledgement within eight hours
of initiation by either a telephone order or verbal order. Acknowledgement by the physician must occur
prior to patient discharge or transfer to a different level of care.
Authentication of the initiated order will occur within 48 hours as defined by the Medical Staff.
Monitoring of nurse initiated orders will include:
• Selection and implementation of the appropriate Pre Printed Order / protocol
• Timely acknowledgement and authentication by the physician / Licensed Independent
Practitioner
Modifications, revisions, corrections, and updates to nurse initiated orders will follow the Network’s
process for making changes to a protocol or pre printed order.
Education to medical and nursing staff regarding nurse initiated orders will occur by way of review of
this policy.
Noting Orders: Written acknowledgement by licensed associates that orders have been reviewed for
accuracy and appropriateness prior to implementation of orders.
Non-Hospital Setting: Off CHN campus – clinics, community-based programs that provide direct
care, CHN skilled nursing facility.
IV. ROLES AND RESPONSIBILITIES
A. Registered Nurse (RN):
• Notes written orders, and accepts verbal, telephone, electronic, and faxed patient care /
treatment orders. The RN taking a telephone or verbal order will write down the order and then
read it back verbatim to the practitioner who initiated it. The practitioner will then verbally
confirm that the order is accurate.
• Reviews all orders for the accuracy of transcription and begins the process of implementation.
• Performs a chart review of orders received during the previous 24 hour period at least daily
to ensure that these orders have been accurately transcribed and implemented.
• Is responsible for supervising the LPN to assure that orders are carried out accurately and
in a safe manner.
B. Licensed Practical Nurse (LPN):
Acute Care setting:
• The Licensed Practical Nurse may note written orders, and may accept verbal, telephone,
electronic, and faxed orders. The LPN taking a telephone or verbal order will write down
the order and then read it back verbatim to the practitioner who initiated it. The practitioner
will then verbally confirm that the order is accurate.
Orders for Medical Treatment
Page 2 of 8
•
•
Reviews all orders for the accuracy of transcription and begins the process of
implementation.
Orders received or noted by an LPN will be reviewed and countersigned by the supervising
registered nurse prior to implementation.
Non-Hospital settings:
• The Licensed Practical Nurse may take handwritten, verbal, telephone, electronic orders
and orders faxed to nursing units. Orders, in the non-hospital setting do not require a
registered nurse counter–signature before implementation.
• It is ultimately the responsibility of the supervising RN to assure that the LPN accepting
orders and carrying out such does so in a safe and correct manner.
• The LPN taking a telephone or verbal order will write down the order and then read it back
verbatim to the practitioner who initiated it. The practitioner will then verbally confirm that
the order is correct.
C.
Pharmacist:
• The Pharmacist may write medication orders taken as a directive from an authorized
prescriber.
• The Pharmacist taking a telephone or verbal order will write down the order and then read
it back verbatim to the practitioner who initiated it.
• The practitioner will then verbally confirm that the order is correct.
• The Pharmacist may also write orders pursuant to a physician consult or drug therapy
management protocol or guideline approved through the Medical Executive Committee.
D.
Respiratory Therapist :
The Respiratory Therapist may accept verbal and telephone respiratory therapy orders, and
implements the treatments as ordered and per established protocol.
E.
Medical Imaging Licensed Personnel
May accept verbal and telephone orders related to imaging procedures and carries out the
procedures as ordered and according to established protocol.
F.
Registered Dieticians:
• Registered Dieticians may accept verbal and telephone orders for dietary / nutritional
therapy.
• The Registered Dietician taking the order will write down the order and then read it back
verbatim to the practitioner who initiated it.
• The practitioner will then verbally confirm that the order is correct.
G.
Other Licensed Personnel
Other licensed clinical personnel may accept verbal and telephone orders and implement the
treatments as ordered within their scope of practice.
H.
Clerical personnel:
• Clerical personnel may NOT accept telephone or verbal orders.
Hospital setting:
• Clerical staff may transcribe written orders onto a kardex. The nurse is responsible for
reviewing the transcribed orders to ensure accuracy.
Non-Hospital setting:
• Orders transcribed by clerical personnel shall be reviewed and countersigned by either
a registered or licensed practical nurse.
V. PROCEDURE
1. All orders for medical treatment shall:
• be in writing in the patient record.
• include the date, time of the order, and signature of the ordering practitioner
• be written clearly, legibly and completely using only approved abbreviations.
• be noted / signed off by appropriately licensed associates.
Orders for Medical Treatment
Page 3 of 8
2. Orders, that are illegible, improperly written, conditional, or ambiguous, will not be carried out
until rewritten or clarified by the ordering practitioner. .
3. All orders dictated over the telephone or given as a verbal order, shall be written in the medical
record by a licensed associate, and must include the date and time received, the signature of the
licensed associate that received the order (including full first and last name), and the full first
and last name of the licensed practitioner that gave the order.
4. Personnel authorized to accept verbal or telephone orders will write down the order and then
read it back verbatim to the practitioner who initiated it. The practitioner will then verbally
confirm that the order is accurate.
5. Verbal orders, if used, must be used infrequently. Verbal orders should only be used to meet
the care needs of the patient when it is impossible or impractical for the ordering practitioner to
write the order without delaying treatment. Verbal orders are not to be used for the
convenience of the ordering physician.
o Verbal orders will not be accepted if the physician is physically present on the patient care
unit at the time the order is given EXCEPT in emergency situations.
Verbal/Telephone Orders will be signed by the prescribing practitioner according to the
following parameters (whichever occurs first):
• The next time care is provided, the patient is assessed, or information is documented in the
patient’s medical record.
• Within 48 hours of when the order was given. EXCEPTION: Verbal orders for restraints or
seclusion shall be signed, dated and timed by the responsible professional staff member by
the next visit, (not to exceed 24 hours)
• Within two (2) business days for outpatient services.
6. STAT orders are those that are deemed emergent by the Practitioner based on the medical
condition of the patient. The following guidelines are utilized by Imaging, Pharmacy,
Laboratory, and Respiratory Therapy to define the expected turn-around time for a STAT:
• Imaging
o Procedures written as STAT are prioritized in the order the STAT requisition is
received by the Imaging Department. The expected time from when the requisition is
received to when the image is conducted is 30 minutes based on patient availability
and completion of exam pharmaceutical prep. Once the exam is completed, the turnaround time for the Radiologist to read the exam is 60 minutes from transmission to
group’s PACS.
• Pharmacy
o STAT—Medications dispensed 15 minutes from time Pharmacy notified
(Medications requiring preparation time may be dispensed outside this timeframe)
o NOW—Medications dispensed 60 minutes from time Pharmacy notified
• Laboratory
o Blood Bank—STAT Units available within one hour from the time the sample is
received in Blood Bank.
o Other Lab Tests—STAT tests are reported within 60 minutes of the receipt in Lab.
• Respiratory Therapy
o Respond/acknowledge STAT requests within 10 minutes. Results and documentation
vary depending on the request. The order in which STAT requests are prioritized is
code arrests, rapid response calls, Critical Care areas, Emergency Centers, and General
Patient care area
MEDICATION ORDERS
1. Only medications needed to treat the patient’s condition are ordered. Each medication
order must have a diagnosis, condition, or indication-for-use documented somewhere in the
patient’s medical record.
2. Medication orders are written clearly and transcribed accurately.
Orders for Medical Treatment
Page 4 of 8
3. Medication orders will contain complete and full information, including patients first and
last name, date and time written, the medication name, strength, route of administration,
administration times or dosing interval, legible signature, and any other pertinent
information. If a dosing interval is not specified, the order will be interpreted as a one time
order.
4. IV solution orders should contain the IV solution, volume, all additives and amounts and
the rate of infusion.
5. In the case of emergent verbal medication orders, there must be a mutual understanding
between the Physician and the RN or other licensed personnel acting within the scope of
their practice of the right patient, right drug, right dose, right route, and right time to be
administered. The RN/licensed personnel will “repeat back” the order(s) completely and
the Physician will then verbally confirm that the order is correct and complete prior to
implementation.
6. Medications may be ordered using generic or trade names. Using both the generic and
trade name should be considered for high-risk medications or for medications with lookalike or sound-alike names. Pre-printed orders will always contain the generic name and
will generally also contain the most common trade name in parentheses.
7. The Pharmacist will clarify incomplete orders with the physician.
8. On admission, the attending physician is responsible for reviewing the patient’s home
medication therapy and for providing complete and full medication orders (written or
verbal). Orders such as “continue medications as at home” or other blanket type orders that
do not list individual medications are not acceptable.
9. The metric system is encouraged when prescribing or reordering medication orders.
10. Use only approved abbreviations on medication orders. See “Unacceptable Abbreviations”
poster available on i-connect.
11. All PRN medication orders are required to contain an indication for use or special
instructions for use (i.e., pain, constipation, blood pressure parameters, pain parameters
etc). This also satisfies the requirement to document the diagnosis, condition, or indicationfor-use for each medication order somewhere in the patient’s medical record.
12. The organization recognizes the following order types and the listed required elements for
each order type:
 PRN Orders: Medication name, Strength, Route, Frequency. (Indication for use or
specific parameters for use are required).
 Standing Orders /Protocol Orders: Standing or protocol orders will be accepted as
approved through the Medical Staff.
 Hold Orders: Hold orders without specific parameters will be discontinued.
 Resume Orders: Resume orders are accepted provided they contain the medication
name, dose, route, and frequency of administration.
 Automatic Stop orders: Physicians may write for a specific time frame for any orders
(i.e., continue for 10 days or for 4 doses etc). Generally, automatic stop dates are not
used for any specific medications or medication classes with the exception of
ketoraolac (Toradol) injection and tablets and any other automatic stop dates
designated by individual institutions.
 Titrating Orders: Titrating orders are accepted and require that the physician specify a
parameter for titrating the dose (e.g. titrate to systolic blood pressure greater than 100)
 Wean Orders: Weaning orders are accepted and will follow the same parameters as the
titration orders.
 Taper Doses: Taper doses are accepted providing that the doses are specified and the
taper schedule is specific and clear.
 Range Orders: See Medication Range Order Policy & Procedure.
 Orders for Compounded/Admixed Medications: Orders for compounded/admixed
medications not commercially available are accepted provided they contain the
medication name(s), Strengths, Diluents or volume (if applicable).
 Orders for Medication Related Medical Devices: Orders for medication related medical
devices are accepted provided they are normally stocked in the hospital.
Orders for Medical Treatment
Page 5 of 8
 Orders for Investigational Medications: See Investigational Drugs or Human Subjects
Committee Policy & Procedure.
 Orders for Herbal Products: See Herbal Medication Policy & Procedure.
 Orders for Medications at Discharge: A Discharge Prescription Form can be printed
from the hospital’s computer system. Prescriptions for controlled substances must be
written on a separate prescription.
 Verbal or Telephone Orders: Refer to this policy.
Pre-Printed Medication Orders: See Hospital Provided Pre-Printed Doctor’s Orders
Policy & Procedure
13. Pediatric Weight Based Dosing: See Guidelines for Writing Weight Based Pediatric
Medication Orders Policy and Procedure.
14. In the event a medication order requires changes, deletions or additions the entire order
must be rewritten.
15. Medication orders will be reviewed and entered into the pharmacy computer system using
standard administration times as established by pharmacy and nursing.
16. Vague directions (e.g. “Take as Directed”) should be avoided. Directions should be
explicitly stated.
17. Medication orders will be suspended when patients transfer from one level of care to
another (i.e. ICU to Med/Surg) or undergoes a surgical procedure. To reorder suspended
medications, a medication Reorder Form must be printed by the physician or nursing
personnel. The physician must review medications listed on the Medication Reorder Form
and check the renew or discontinue column for each medication; sign, date and time this
form. If the physician is not available, the patient’s nurse may review each medication
order or the Medication Reorder Form with the physician and follow the verbal order
process. Orders to “continue same medications,” “resume pre-op medications” or other
blanket orders will not be accepted.
18. All order sets and protocols are subject to regular reviews and updates consistent with CHN
protocol for review of order sets and clinical protocols.
VI.
SPECIAL CONSIDERATIONS
Students
Students may not independently note or implement patient care orders. All orders for treatment and
procedures are to be countersigned by and implemented under the supervision of appropriately licensed
associates.
Read Back in Emergency Situations
• In certain situations, such as cardiopulmonary arrest or an extreme emergent patient condition, it
may not be feasible to write the order for a formal “read back” of orders. In such cases the RN or
other licensed personnel acting within the scope of their practice will “repeat back” the order(s)
completely and the Physician will then verbally confirm that the order is correct and complete prior
to implementation. The RN will write the order as soon as possible after the emergency.
Clarification of Orders
• If clarification is needed, all pertinent information and questions should be directed to the physician
writing / initiating the order.
• If questions remain after consulting with the physician, the Unit Manager/Clinical Nursing
Supervisor should be contacted to assist in resolution.
• If no resolution is obtained, the Chain of Command Policy should be followed.
Outpatient Orders from Non-Credentialed Prescribers
• Outpatient orders given by a non-credentialed prescriber must be clarified and reordered by a
credentialed prescriber. The complexity and length of outpatient orders result in a high risk for
transcription error. It is therefore acceptable to read the order to the clarifying credentialed
prescriber but not re-write it. The documentation for the telephone order read back may be
documented at the end of the original order written by the non-credentialed prescriber.
Orders for Medical Treatment
Page 6 of 8
Do Not Resuscitate Telephone Orders
• “Do Not Resuscitate” telephone orders must be witnessed by two nurses.
Withdrawal of Life Support Orders
• Verbal orders to a nurse for withdrawal of life support will NOT be accepted.
• Telephone orders for the withdrawal of life support IS acceptable but must be witnessed and noted
by two RNs, and countersigned by the physician within 24 hours.
VII.
DOCUMENTATION
1. Noting orders should include date, time, and the signature and title of nurse noting the order.
2. 24-hour order checks should include time span checked, date, time, and signature/title of nurse.
3. Verbal or Telephone orders should include date, time and type of order (verbal or telephone).
The first and last name of ordering physician and the signature and title of the individual taking
the order should be included.
4. Nurse Initiated orders will include the date, time, and signature of the initiating RN, the date, time,
and name of the acknowledging physician / LIP
VIII.
REFERENCES
• Arizona State Board of Nursing. (2009). Advisory Opinion: Orders: Accepting,
Transcribing, Reviewing Orders. Accessed 11/11/09 at
http://www.azbn.gov/documents/advisory_opinion/AO%20ORDERSACCEPTING%20TRANSCRIBING%20REVIEWING%20ORDERS%202009.pdf
• Arizona Revised Statues. Title 32: Professions and Occupations. Chapter 15: Nursing.
Article 1: nursing. 1601: Definitions. Accessed 11/13/09 at
http://www.azleg.state.az.us/FormatDocument.asp?inDoc=/ars/32/01601.htm&Title=32&DocT
ype=ARS
• Arizona Department of Health Services. (2002). Rule R-9-10-215.D: Health Services,
Healthcare Institutions Licensing, Anesthesia Services. Accessed 11/13/09 at
http://www.azsos.gov/public_services/title_09/9-10.htm.
• Arizona Administrative Code. (1995). Rule R4-19-402.B: Scope of Practice for a
Professional Nurse. Accessed 11/13/09 at http://www.azsos.gov/public_services/Title_04/419.htm#ARTICLE%204.%20REGULATION
• Centers for Medicare & Medicaid Services, Department of Health & Human Services. (2008).
Memorandum Summary: Hospitals – Revised Interpretive Guidelines for Hospital Conditions
of Participation: Requirements for History and Physical Examinations; Authentication of
Verbal Orders; Securing Medications; and Post-anesthesia Evaluations Final Rule. Accessed
on 10/23/09 at http://www.cms.hhs.gov/surveycertificationgeninfo/downloads/SCLetter0812.pdf.
• Centers for Medicare & Medicaid Services, Department of Health & Human Services. (2008,
October 24). Memorandum Summary: “Standing Orders” in Hospitals - Revision to S&C
Memoranda, accessed on January 19, 2012 at
https://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-10.pdf
•
Centers for Medicare & Medicaid Services, Department of Health & Human Services. (2011,
October 24). Federal Register / Vol. 76, No. 205/Monday, October 24, 2011/Proposed Rules,
accessed on January 19, 2012 at
https://www.cms.gov/CFCsAndCoPs/Downloads/CMS3244P.pdf
Orders for Medical Treatment
Page 7 of 8
IX. APPROVALS
Committee/Department
CHN Pharmacy & Therapeutics
Medical Executive Committee - CSM
Medical Executive Committee- CSJ
Medical Executive Committee - CHC
Medical Executive Committee - CHVI
Patient Care Services Policy &
Procedure Committee
Network Nursing Leadership Council
Orders for Medical Treatment
Page 8 of 8
7th
Review
4/09/10
4/22/10
4/22/10
4/22/10
5/14/10
5/13/10
8th
Review
01/07/11
1/27/11
1/27/11
1/20/11
1/26/11
1/13/11
4/23/12
6/25/12
9th
Review
5/06/11
5/19/11
5/19/11
5/26/11
5/25/11
6/09/11
10th
Review
3/2/12
4/26/12
4/26/12
4/26/12
4/25/12
5/11/12
11th
Review
6/13/12(e)
6/28/12
6/28/12
6/28/12
6/27/12
7/02/12
12th
Review