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Respiratory Therapy Orders in Hospitals

PDF Version of DQA 11-004  (PDF, 42 KB)

Date: January 28, 2011 -- DQA Memo 11-004
To: Hospitals HOSP 02
From: Cremear Mims
Bureau of Health Services

Otis Woods, Administrator
Division of Quality Assurance

Respiratory Therapy Orders in Hospitals

The purpose of this memo is to inform hospitals regulated by the Division of Quality Assurance (DQA) about a statewide variance of DHS 124 related to respiratory therapy orders.

Currently DHS 124.22(4) states the following:

PHYSICIAN'S ORDERS. Respiratory care services shall be provided in accordance with the orders of a physician. Oral orders given by a physician shall be transcribed into the medical record by the staff person authorized to take the orders.

On August 16, 2010, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that took effect on October 1, 2010 regarding Conditions of Participation (CoPs) for hospitals
42 CFR 482.57: Respiratory Services and who may order respiratory services. The rule allows a qualified, licensed practitioner who is responsible for the patient and acting within the scope of their practice to order respiratory or rehabilitation services.

In Survey and Certification letter 11-04 issued November 26, 2010, CMS notified state survey agencies about the change and provided the following summary:

CMS revised the existing requirements at 482.57 to allow qualified, licensed practitioners as well as physicians, to order respiratory care services as long as such privileges are authorized by the medical staff and are in accordance with both hospital policies and procedures and State laws. As is required under the CoPs for all patient orders, the ordering practitioner must also be an individual who is responsible for the care of the patient. The revised rule also requires that all orders for these services be documented in accordance with the requirements at 482.24, Medical records.

To ensure regulatory consistency, pursuant to this memo, effective immediately the Division of Quality Assurance is issuing a statewide variance for DHS 124.22(4) to allow licensed practitioners, who are authorized via their practice act and are granted privileges by the medical staff of the hospital, to order respiratory care services.

If you have any questions regarding this variance, contact:

Jan Heimburch
P.O. Box 2969
Madison, WI 53701-2969
(608) 266-0371 
Mark Andrews
P.O. Box 2969
Madison, WI 53701-2969
(608) 266-0269


cc: Michelle Doro, DQA


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Last Updated: September 30, 2011