Verbal/Telephone Order Authentication and Time Frames (Updated)

Editor’s note: This update replaces the June 2010 practice brief “Verbal/Telephone Order Authentication and Time Frames.”

It is important for a healthcare facility to review and understand all applicable federal and state laws and accreditation standards when developing policies and procedures for acceptance and authentication of verbal and telephone orders. This practice brief outlines the federal laws from the Code of Federal Regulations (CFR) and The Joint Commission (TJC) standards that apply to verbal and telephone orders, as well as the time frames for authentication, if applicable.

In general, the federal regulations and accreditation standards do not prescribe a specific time frame for authentication. This information is usually in state licensure regulations. Therefore, it is imperative to refer to individual state laws and regulations to ensure full compliance.

Consider the following steps when researching regulations and standards for development of organizational policy and procedures pertaining to acceptance and authentication of verbal/telephone orders:

  • Research applicable federal regulations. Not all healthcare settings are governed by federal law. If your organization is not subject to federal law, use accreditation standards, state regulations, and professional practice standards in policy development.
  • If your organization is accredited by a third party, such as the Joint Commission, research applicable standards pertaining to verbal orders. Even if you are not accredited, standards for organizations similar to yours can provide a foundation for establishing procedures.
  • Search all applicable state statutes to determine if there are state regulations governing your practice setting. Some states have regulations according to practice setting, and others have general statutes pertaining to licensed healthcare facilities.
  • When developing policies, make sure they meet all laws and standards, which usually means developing a procedure to meet the most stringent law or standard required. For example, if state regulations require verbal orders to be signed within 48 hours but accreditation and federal law do not specify a time frame, your organization should develop a procedure that meets the state law and should create policies that follow professional practice standards. Most practice settings have laws and standards that require clinical records to be complete, accurate, and timely. Your facility policies should address these issues and determine the time frame in which verbal and telephone orders are to be authenticated.

Federal Regulations and Joint Commission Standards for Verbal/Telephone Orders

(iii) Orders for drugs and biologicals may be documented and signed by other practitioners not specified under 482.12(c) only if such practitioners are acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.

Practice Setting Federal Regulation Joint Commission Standard
Hospitals, hospital-based outpatient services, specialized rehabilitation facilities/units 42 CFR 482.23(c) (3) With the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved hospital policy after an assessment of contraindications, orders for drugs and biologicals must be documented and signed by a practitioner who is authorized to write orders in accordance with State law and hospital policy, and who is responsible for the care of the patient as specified under §482.12(c).

(i) If verbal orders are used, they are to be used infrequently.

(ii) When verbal orders are used, they must only be accepted by persons who are authorized to do so by hospital policy and procedures consistent with Federal and State law.

RC 02.03.07
  1. The organization identifies, in writing, the staff who are authorized to receive and record verbal orders, in accordance with law and regulation.
  2. Only authorized staff receive and record verbal orders.
  3. Documentation of verbal orders includes the date and the names of individuals who gave, received, recorded, and implemented the orders.
  4. Verbal orders are authenticated within the time frame specified by law and regulation. Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: If there is no state law that designates a specific time frame for authentication of verbal orders, the verbal orders are authenticated within 48 hours. Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: In some instances, the ordering practitioner may not be able to authenticate his or her verbal order (for example, the ordering practitioner gives a verbal order that is written and transcribed, and then he or she is “off duty” for the weekend or an extended period of time). In such cases, it is acceptable for another practitioner who is responsible for the care of the patient to authenticate the verbal order of the ordering practitioner.
  5. For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of verbal orders includes the time the verbal order was received.
Ambulatory care facilities See hospital regulations above if providing hospital-based outpatient services. RC 02.03.07
  1. The organization identifies, in writing, the staff who are authorized to receive and record verbal orders, in accordance with law and regulation.
  2. Only authorized staff receive and record verbal orders.
  3. Documentation of verbal orders includes the date and the names of individuals who gave, received, recorded, and implemented the orders.
  4. Verbal orders are authenticated within the time frame specified by law and regulation.
Medicare-certified ambulatory surgical treatment facilities Regulations do not contain specific language relating to physician order authentication and time frames except for the listed regulation below.

42 CFR 416.48 (a) (3) Orders given orally for drugs and biologicals must be followed by a written order, signed by the prescribing physician.

PC 02.01.03

  1. For ambulatory surgical centers that elect to use The Joint Commission deemed status option: Prior to providing care, treatment, and services, the ambulatory surgical center obtains orders from practitioners with clinical privileges, in accordance with professional standards of practice, or from other practitioners authorized by the medical staff and the governing body, consistent with state law.
  2. Before taking action on a verbal order or verbal report of a critical test result, staff uses a record and "read back" process to verify the information.
Hospice services 42 CFR 418.106 (b) (2) If the drug order is verbal or given by or through electronic transmission—

(i) It must be given only to a licensed nurse, nurse practitioner (where appropriate), pharmacist, or physician; and

(ii) The individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with State and Federal regulations.

See standards for Hospitals (AMH)
RC. 02.03.07
End-stage renal disease treatment centers Regulations do not contain specific language relating to physician order authentication and time frames.  

References

Centers for Medicare and Medicaid Services, Department of Health and Human Services. “Conditions of Participation for Ambulatory Surgical Services.” Code of Federal Regulations, 2012. 42 CFR Chapter IV, Part 416.

Centers for Medicare and Medicaid Services, Department of Health and Human Services. “Conditions of Participation for End Stage Renal Facilities.” Code of Federal Regulations, 2012. 42 CFR, Chapter IV, Part 494.

Centers for Medicare and Medicaid Services, Department of Health and Human Services. “Conditions of Participation for Hospice Care.” Code of Federal Regulations, 2012. 42 CFR, Chapter IV, Part 418.

Centers for Medicare and Medicaid Services, Department of Health and Human Services. “Conditions of Participation for Hospitals.” Code of Federal Regulations, 2012. 42 CFR, Chapter IV, Part 482.

The Joint Commission. Comprehensive Accreditation Manual for Ambulatory Care, E-dition. Oakbrook Terrace, IL: 2012.

The Joint Commission. Comprehensive Accreditation Manual for Hospitals, E-dition. Oakbrook Terrace, IL: 2012.

Prepared by

Marlene L. Johnson, RHIA

Prepared by (2010 update)

Angela K. Dinh, MHA, RHIA, CHPS

Prepared by (original)

Michelle Dougherty, MA, RHIA, CHP


Article citation:
American Health Information Management Association. "Verbal/Telephone Order Authentication and Time Frames (Updated)." Journal of AHIMA (Updated online, August 2012).