Variance of Section HFS 124.12(5)(b)11, Wisconsin Administrative
Code: Authentication of Physician Orders in Hospitals
PDF Version of OQA 07-004 (PDF,
36 KB)
| Date: |
| March 13,
2007 -- OQA - 07-004 |
|
Supersedes 06-006 |
|
| To: |
Hospitals Hosp 02 |
| From: |
Otis Woods, Director
Office
of Quality Assurance |
Variance of Section HFS 124.12(5)(b)11, Wisconsin Administrative Code:
Authentication of Physician Orders in Hospitals
This memo supersedes DDES-BQA-06-006, issued May 2, 2006. The variance
granted in DDES-BQA-06-006 is revoked and replaced by the variance in this
memo, which explains the Department's current position on authentication
of physician orders in hospitals and aligns the state requirements with
federal Medicare regulations.
History
The State rule governing physician authentication, section HFS
124.12(5)(b)11, Wisconsin Administrative Code, states that:
Medical staff by-laws and rules shall include…a statement
specifying categories of personnel duly authorized to accept and
implement medical staff orders. All orders shall be recorded and
authenticated. All verbal and telephone orders shall be authenticated by
the prescribing member of the medical staff in writing within 24 hours
of receipt.
The Department of Health and Family Services (DHFS or Department) has
issued a number of variances of this requirement, as described in
DDES-BQA-06-006; DDES-BQA-06-002; DSL-BQA-05-010; DSL-BQA-00-015; and
DSL-BQA-98-050.
As a matter of public policy, DHFS does not intend to have rules, rule
interpretations, variances, or waivers that, if implemented, would put a
hospital out of compliance with Medicare regulations.
New Medicare regulations addressing section 42 CFR 482.23, Condition of
Participation: Nursing Services, were published in the Federal Register /
Vol. 71, No. 227 / Monday, November 27, 2006, and became effective January
26, 2007.
New Variance:
Effective immediately, the Department grants a statewide variance of
section HFS 124.12(5)(b)11, Wisconsin Administrative Code, the State rule
governing physician authentication as follows:
Medical staff by-laws and rules shall include…a statement
specifying categories of personnel duly authorized to accept and
implement medical staff orders. All orders shall be recorded, dated,
timed, and authenticated. All verbal and telephone orders shall be
dated, timed, and authenticated in writing by a practitioner who is
authorized to write orders by hospital policy within 48 hours of
receipt.
Paralleling new federal regulations, this variance now applies to all
verbal and telephone orders, not just orders for drugs and biologicals.
The federal regulation applies to all components of the hospital that are
certified by the Centers for Medicare and Medicaid Services (CMS). Please
note that section HFS 124.12(5)(b)11 applies only to inpatient orders.
The Department continues the previous State interpretation of this
provision as it concerns authentication by physicians other than the
prescribing physician, as follows: "The hospital may develop medical
staff by-laws and hospital policies delineating circumstances under which
a physician, who is a member of the medical staff, may sign verbal or
telephone orders, as well as the histories and physicals done by other
physicians who are members of the medical staff. This is done with the
understanding that the signing physician is then professionally and
legally responsible for the treatments and medications prescribed under
the orders, as well as the diagnostics on which the orders are
based." This long-standing State interpretation is consistent with
CMS's comments in the Federal Register, November 27, 2006:
Ultimately, the prescribing practitioner is responsible for
authenticating the verbal order. A hospital has the flexibility to
develop policies and practices to implement this regulation in a manner
that makes sense for their hospital based on the needs of the patient
population served. When a practitioner authenticates a verbal order that
he or she did not give, the practitioner accepts responsibility for the
order and is validating that the order is complete, accurate, and final
based on the patient's condition. We expect a practitioner responsible
for the care of the patient to have knowledge of the patient's hospital
course, medical plan of care, condition and current status. A
practitioner who does not possess this knowledge about a patient should
not be authenticating verbal orders for this patient.
Another change in Medicare regulations, pertaining to authentication of
verbal orders and incorporated in the new variance of section HFS
124.12(5)(b)11, is that the definition of "practitioner who is
authorized to write orders by hospital policy" now includes physician
assistants, and in Wisconsin, advanced practice nurse prescribers. CMS
comments in the Federal Register, November 27, 2006, are as follows:
A physician assistant or nurse practitioner may only authenticate
verbal orders written by a physician or other licensed independent
practitioner that they have authority to write themselves as determined
by hospital policy in accordance with state law. For example, some
hospitals limit who may give orders for certain types of drugs or
therapies. If a physician assistant or nurse practitioner is not
permitted by hospital policy to order a specific drug or therapy, he or
she would not be permitted to authenticate a verbal order for such a
drug or therapy. Hospitals have the flexibility to limit who may
authenticate verbal orders. In addition, a physician assistant or nurse
practitioner may only authenticate verbal orders for a patient for whom
they have physician delegated responsibility. Like all practitioners
responsible for the care of the patient, a physician assistant or nurse
practitioner would be expected to have knowledge of the patient's
hospital course, medical plan of care, condition and current status.
With this knowledge, a practitioner can safely evaluate the completeness
and accuracy of a verbal order.
In Wisconsin, the only registered nurses who may write hospital orders
are advanced practice nurse prescribers (APNP). The Department of
Regulation and Licensing interpretation of the authority of APNPs is that
such individuals may issue an order for medications verbally or in writing
directly to the hospital pharmacy. The APNP may not give the order
verbally to an RN, LPN, ward clerk, or administrative assistant to either
call the order in to the pharmacy or write the order in the medical record
for conveyance to the pharmacy.
The new CMS regulations regarding authentication of verbal orders are
scheduled to "sunset" after five years. The Department will
address any changes in those regulations that may be made at that time.
Following is a link to the Federal Register of November 27, 2006, which
contains CMS comments and the final rule:
http://edocket.access.gpo.gov/2006/pdf/E6-19957.pdf
(exit DHFS).
Please note that the position of CMS continues to be that, "The
use of verbal orders should be limited to those situations in which it is
impossible or impractical to write the order or enter it into the
computer. Verbal orders are not to be used for the convenience of the
ordering practitioner." This is the same standard of practice that
the Department expects hospitals to follow.
The Department has found significant noncompliance with the existing
federal regulations at section 42 CFR 482.24(c)(1). Relevant CMS comments
in the Federal Register are:
This requirement maintains and reinforces the current regulation for
authentication of all medical record entries. It requires that all
patient medical record entries be legible, dated, timed, and
authenticated in written or electronic form by the person responsible
for providing or evaluating a service provided. This standard has not
been revised and, therefore, is being finalized without change.
The federal regulation requiring dating and timing of all patient
medical record entries is consistent with section HFS 124.14(3)(a)12,
which requires that, "…each patient's medical record contains…physician
notes and non-physician notes providing a chronological picture of
the patient's progress which are sufficient to delineate the course and
the results of treatment; [emphasis added.]" and with section HFS
124.24(2)(d)1.i, which requires that emergency room patient records
contain:
Appropriate time notations, including time of the patient's arrival,
time of physician notification, time of treatments, including
administration of medications, and time of patient discharge or transfer
from the service.
Accordingly, language specifically stating that all orders shall be
dated and timed has been included in the new waiver.
Any questions regarding this memo may be directed to the Office of
Quality Assurance, Health Services Section, at (608) 243-2024, or the
Office Director, Otis Woods, at (608) 267-7185.
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