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Physician Orders and Medications

PDF Version of BQA 04-026 (PDF, 66 KB)

Date: November 22, 2004 -- DDES-BQA 04-026

To: Adult Day Care ADC - 07, Adult Family Homes AFH - 10, Community Based Residential Facilities CBRF - 13, Residential Care Apartment Complexes RCAC - 04

FROM: Kevin Coughlin, Chief, Assisted Living Section, Bureau of Quality Assurance

cc: Cris Ros-Dukler, Director, Bureau of Quality Assurance

ISSUE

What constitutes a written physician order?

DISCUSSION

In assisted living facilities and adult day care settings, the regulations or standards may indicate that a written order is required from a physician before staff can administer medications. In the context of the regulations and standards, the physician order typically involves two types of orders: One order for the medication itself. For example, "warfarin 5 mg once a day." The other grants authorization for certain staff to administer the medication to the resident or client. For example, "all resident assistant staff who have taken medication training may administer medications to Ms. Jones."

The second type of order authorizing staff to administer medications is straightforward and usually is not a barrier for facilities when providing medications to residents or clients. The first type of order, however, does become a barrier. Typically the barrier occurs because the resident comes back from a doctor’s visit on a Friday afternoon and has new medications. The facility does not have orders and are unable to reach the doctor to obtain them until the following Monday. Another scenario is when a facility uses a medication administration record (MAR), which the pharmacy generates monthly. The physician may sign it monthly, quarterly or annually or the pharmacy signs the MAR verifying the medication orders. The question is are these signed MARs written orders? The balance of this memo addresses what meets the requirement for a written physician order.

ANALYSIS

  • Adult Day Care

Standard I.F. (3)(a)—A written order from the prescribing practitioner must be in the record.

  • Adult Family Homes (AFH):

Wis. Admin. Code § HFS 88.07(3)(d)—Before a licensee or service provider dispenses or administers a prescription medication to a resident, the licensee shall obtain a written order from the physician who prescribed the medication specifying who by name or position is permitted to administer the medication, under what circumstances and in what dosage the medication is to be administered.

  • Residential Care Apartment Complex (RCAC):

There are no regulations that specifically address physician orders for medications.

  • Community Based Residential Facilities (CBRF)

Wis. Admin. Code § HFS 83.33(2)(h)1. Each CBRF shall ensure that there is a physician’s written order for nursing care, medications, rehabilitation services and therapeutic diets provided or arranged by the CBRF.

Wis. Admin. Code § HFS 83.33(3)(a)1. Practitioners Order. There shall be a practitioner’s written order for any prescription medication taken by or administered to a CBRF resident and that medication shall be labeled by a pharmacist. Any change in a practitioner’s order for any prescription or over-the-counter medication shall be communicated promptly to the CBRF staff responsible for the resident’s medication.

Wis. Admin. Code § HFS 83.33 (3)(e)2.a. A CBRF staff member may not administer a prescribed or over-the-counter medication unless the staff member has a written medical order from a practitioner to administer the medication and complies with the subd. 3 or 4. The practitioner’s order shall identify the name of the resident, the medication and the names of the specific staff persons or staff person identified by the CBRF to administer medications on the staff position’s job description.

RESULT

A written physician order for specific medications can include the following:

  1. Written order mailed, faxed, or hand delivered from the physician.
  2. A MAR signed by the physician that is faxed, mailed, or hand delivered.
  3. A copy of a prescription that is faxed, mailed, or hand delivered by the pharmacist (pharmacists have specific regulations that allow providing a copy of a prescription to a patient).
  4. A MAR signed by the pharmacist based on prescription orders signed by physician that pharmacist has on file.
  5. The facility shall obtain one of the order types noted above within two business days. While waiting for a written order of types 1-4 above, a facility can follow the instructions on the prescription label. This should happen only in situations where the pharmacy or physicians are unavailable to provide the written order.
  6. In facilities using MAR orders (see 2 and 4), changes to the MAR by the facility after the pharmacist or physician signs it, shall also have a written order of the type in 1, 3 or 5. Staff can transcribe to the MAR but must have a written order on file.

Physician Written Order

Facility Type

CBRF

AFH

RCAC

ADC

Written order indicating staff can administer.

Y

Y

Silent

N

(Facility policy required)

Written order indicating which staff can administer.

Y

Y

Silent

N

(Facility policy required)

Written order for each medication

Y

Y

Y

(all prescription drugs require a physician order at a pharmacy

Y

Written order for each medication when resident Self Administers

Y

N

N

N

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