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Variance of Chapter HFS 124, Wisconsin Administrative Code, Extending Time for Authentication of Physician Orders to 72 hours.  Effective Date - Immediate.

PDF Version of BQA 98-050 (PDF, 6 KB)

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Date: September 4, 1998 DSL-BQA 98-050

To: Hospitals HOSP 19

From: Judy Fryback, Director, Bureau of Quality Assurance

The Department of Health and Family Services has examined issues involved in application of the current rule governing physician authentication found at Section DHS 124.12(5)(b)11, Wisconsin Administrative Code (exit DHS), which 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.

Numerous hospitals and physicians have claimed that strict interpretation of this code presents an unreasonable hardship on Wisconsin hospitals and that authentication in 72 hours, rather than 24 hours, will not adversely affect the health, safety or welfare of any patient.

The Bureau of Quality Assurance concurs with this position, and intends a future revision of this administrative code. It is the Bureau's opinion that 72 hours is a reasonable time for authentication.

In lieu of granting facility-specific variances of this requirement, the Department has decided to issue a statewide variance of Section DHS 124.12(5)(b)11, Wis. Adm. Code. Accordingly,DHS 124.12(5)(b)11, Wis. Adm. Code, is deemed to be met if medical staff by-laws and rules include the requirement that all verbal and telephone orders shall be authenticated by the prescribing member of the medical staff in writing within 72 hours of receipt. The phrase, "in writing," includes electronic authentication that meets the intent of the confidentiality requirements of Chapter DHS 124 found in Section DHS 124.14, Medical record services.

The Department reserves the right to revoke this variance at any time, either through rule making or for other reasons of patient health, safety or welfare.

Any questions regarding this memo may be directed to Beth Stellberg, Chief, Health Services Section (replaced by Cremear Mims).

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