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Authentication of Physician Orders 
in Hospitals

PDF Version of DQA 12-012  (PDF, 41 KB)

Date: August 7, 2012 
DQA Memo 12-012
Superseds DQA Memo 07-019
To: Hospitals HOSP 04
From: Cremear Mims, Director
Bureau of Health Services

Otis Woods, Administrator
Division of Quality Assurance

Authentication of Physician Orders in Hospitals

This memo supersedes DQA Memo 07-019 issued October 27, 2007 and repeals the statewide variance of Section DHS 124.12(b)(b)11, Wisconsin Administrative Code: Authentication of Physician Orders in Hospitals. Effective July 16, 2012, CMS regulations regarding authentication of verbal orders within 48 hours has sunset. The new federal standard refers to state law to determine timely authentication. Current State rule governing physician authentication, section DHS 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. 

DHS 124.04 allows for the granting of a variance requested by a hospital if it does not “adversely affect the health, safety or welfare of any patient” and that “strict enforcement of a requirement would result in unreasonable hardship on the hospital or on a patient.” If a hospital wishes to request a variance of the requirement identified in DHS 124.12(5)(b)11, please submit the request to adhere to a 48 hour timeframe via email to and include the following:

  1. The rule from which the variance is requested (DHS 124.12(5)(b)11); 
  2. The time period for which the variance is requested; 
  3. The specific alternative action which the facility proposes (48 hours instead of 24 hours); 
  4. The reasons for the request; and 
  5. Explanation that the variance will not adversely affect the health, safety or welfare of any patient and enforcement of the requirement would result in hardship on the hospital or on a patient.

DQA will review and respond to these requests as quickly as possible. If you have any questions about this change, please call or email: Jan Heimbruch, Section Chief at (608) 266-0371 or or Lora Quinn, Section Chief at (608) 266-0269 or


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Last Updated: May 02, 2013