News: Conditions of Participation eases 48 hour requirement for signing orders

CDI Strategies - Volume 6, Issue 15

The proposed rule changes for the Conditions of Participations (CoP) were recently finalized. They include some relief regarding rules for physicians signing, dating, and timing verbal orders within 48 hours of the order being given.

According to the new rule, HHS eliminated the requirement for authentication of verbal orders within 48 hours if no state law specifying a time frame exists.
 
It also allows for orders to be authenticated by another practitioner who is responsible for the care of the patient and who, in accordance with hospital policy state law, is authorized to write orders.
 
According to the final rule, CoPs for medical record services must include the following criteria:
 
“All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with state law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.”
 
 
Hospitals may use preprinted and electronic standing orders, order sets, and protocols for patient orders only if the hospital:
  • Establishes that such orders and protocols have been reviewed and approved by the medical staff and the hospital's nursing and pharmacy leadership
  • Demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines
  • Ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff and the hospital's nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols
  • Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient's medical record by the ordering practitioner or by another practitioner responsible for the care of the patient only if such a practitioner is acting in accordance with state law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations
If you work in a state that adheres to the 48-hour rule, HIM directors should work with your hospital association or licensing agency to revise the time requirement. A suggested policy might state that verbal orders are signed as soon as possible, but no later than 30 days of the order being given.
There are many other changes to the CoPs that benefit hospitals.
 
 
Editor’s Note: This article was originally published in the July issue of Medical Records Briefing.
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News, Quality & Regulatory