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Verbal orders require immediate action by individuals who are practicing within the scope of their licensure, certification or practice in accordance with law and regulation, as well as organizational policy (The Joint Commission, 2020). Verbal orders are inherently subject to risk of error.
As it is now, Joint Commission-accredited hospitals must have verbal orders authenticated, timed, and dated within a 48-hour time frame. And that authentication can be handled by covering physicians.
Verbal order means a directive that is orally communicated to a licensed pharmacist to accept a prescription order by a person who is authorized to communicate a prescription.
Orders that are given by a healthcare provider that are either spoken in person or given by telephone to an authorized staff member for execution. The following health professionals provide verbal orders: licensed healthcare provider, Physician Assistant (PA), or Advanced Nurse Practitioner (ARNP).
Verbal orders may be enacted immediately by individuals who are administering care within the scope of their licensure, certification, or credentialing. There are no CMS limitations on the use of verbal orders in the community (ambulatory care) setting.
To transcribe a medication order, take the information from the prescribing practitioner's order and write it in the proper place on the Medication Log. This is called making a medication log entry. As an authorized provider, it is your responsibility to transcribe medication orders.
The qualified nurse must write the verbal prescription on the appropriate part of the patient's prescription chart before the drug is administered. The qualified nurse must also write 'verbal order', their own signature and their own surname in capitals in the Comments box of the prescription.
Record the order word-for-word on the health care provider's order sheet or enter it into a computer. First, note the date and time. On the next line, write "telephone order." (Don't use P.O. for phone order-it could be mistaken for "by mouth.") Then write the health care provider's name, and sign your name.
The Telephone/Verbal Order must include:Patient's name, ID# and HID/LOC #(LHDs may use the L label)Signature/title of the Health Professional receiving the order.Date and Time the order was received.Orders must include:
All verbal orders should be immediately written and signed by the individual receiving the order indicating the author of the order. Verbal orders should be documented in the patient's medical record, reviewed, and countersigned or authenticated by the prescriber in accordance with organizational policy.