Documentation requirements – hospital | Economics homework help

List each standard that applies and then select the strictest to include in your policy.

Joint Commission Standard RC.02.03.07: Qualified staff receive and record verbal orders.

Elements of Performance for RC.02.03.07 3. Documentation of verbal orders includes the date and the names of individuals, who gave, received, recorded, and implemented the orders

State Licensure Rules (IL) Section 250.1510 Medical Records b)Organization 5c) 
Authentication of Medical Record Entries 1) All entries into the medial record shall be authenticated by the individual who made or authorized the entry. 

CMS Conditions of Participation A-0454: All orders, including verbal orders, must be dated, timed and authenticated promptly by the ordering practitioner … 

Analysis of the Standards: CMS has the strictest policy of the three as it requires not only dating and signing but timing as well.

Recommended Policy: All verbal orders must include the date and time of the verbal order and the name of the individual physician who gave the verbal order. All orders must be authenticated by the ordering physician within 24 hours.







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