TITLE: Processing Provider Orders: Inpatient and Outpatient

Transcription

1 POLICY and PROCEDURE TITLE: Processing Provider Orders: Inpatient and Outpatient Number: Version: Type: Patient Care Author: Janice Dinner; Provider Order Policy Committee Effective Date: 11/21/2011 Original Date: 4/1/2011 Approval Date: 7/14/2011 Deactivation Date: Facility: System Population (Define): All Employees Replaces: Approved by: Administrative Policy Committee, Senior Management Team TITLE: Processing Provider Orders: Inpatient and Outpatient I. Purpose/Expected Outcome: A. To provide guidelines to meet regulatory agency requirements and the medical staff rules and regulations with regard to Provider orders. II. Definitions: A. CPOE: Computerized Physician Order Entry B. EMR: Electronic Medical Record where the documentation is retained in only an electronic format. Any paper-based documentation is scanned and retained in the electronic system. C. Favorite Orders: a set of orders that each Provider can build within CPOE based on individual preferences. D. HIMS: Health Information Management Services E. HUS/HUC: Health Unit Secretary; Health Unit Coordinator F. Hybrid Medical Record: Documentation, both electronic and paper, of the health-related services provided to an individual in any aspect of healthcare delivery or of the healthcare status of such individual. G. Order Set: a preprinted or electronic set of orders subject to approval by the provider. Order Sets may permit the inclusion of additional orders. Such tools may include a menu of medications or actions and/or a combination of medications and actions to be followed without amendment whenever the Provider selects that order. H. Preference(s) or Preference Cards: Preference cards identify individual Provider supply and instrument preferences which do not require a Provider order. I. Protocols: Flow process that generally includes branch points (if/then statements), which can be objective or subjective (requiring judgment), that describes the steps of care during a period of care continuum. Patient-care protocols are often interdisciplinary and describe the care and management of a broad patient care problem or issue. J. Provider: Physician, physician assistant, advance practice registered nurse, dentist, podiatrist, or other licensed independent practitioner who can write orders. K. Standing Order: an order approved by the applicable Medical Executive Committee that may be executed prior to an individual Provider order. Standing Orders are limited to a subset of orders in regards to a patient condition or circumstance that are necessary for timely and efficient care. L. Telephone/Verbal Order: An order not directly written by the provider. Telephone orders are those orders received verbally over the telephone. Verbal orders are orders given in a face-to-face situation. May not be current policy once printed 1 Print Date: 1/17/2012

2 III. Policy: A. General Information: 1. A Provider order is required to admit a patient, place a patient in Observation or Extended Recovery, discharge a patient, transfer a patient to another physician or care facility or unit, and for all tests, services, therapies, and procedures. Exceptions may be made when implementing an order based on a medical staff approved Standing Order or facility/department specific medical staff approved Protocol. A Provider order is not required for the provision of services that are provided to the community at large or for direct access testing (e.g. Wellness Health Fairs, Cardiac Scoring, screening mammograms). 2. All orders, including electronic, verbal, telephone, printed or handwritten, will be documented as a permanent part of the patient's medical record. 3. All orders must be dated and timed when documented or initiated. Outpatient orders are not required to be timed. 4. All orders (including verbal and telephone orders) must be authenticated by the responsible Provider within the time period specified by the facility rules and regulations, not to exceed 48 hours or as required by state regulations. Authentication must include the time and date of the authentication. All orders entered into the EMR are electronically authenticated, dated and timed. 5. Orders as originally written or initiated cannot be changed or modified once performed. 6. Orders containing unapproved abbreviations will be clarified with the responsible Provider prior to initiating the order. 7. Clarified orders must be re-written or re-initiated as a new order. 8. Whenever possible, Provider orders will be entered directly by the Provider into the electronic order entry system in facilities with Computerized Physician Order Entry (CPOE). When the computer order entry system is unavailable, orders should be documented on Banner Health Order form(s). Exceptions may be made as outlined in the Medical Record Forms and External Documents Policy and for orders submitted for outpatient testing, services, and therapies. 9. According to the nursing scope of practice specific to each state and to hospital policies, Registered Nurses may enter orders for dietary or wound care consults as appropriate. 10. If the Provider does not have the ability to access EMR/CPOE to input orders themselves or if a delay in accepting the order could adversely affect patient care, telephone/verbal orders may be accepted by appropriate facility personnel. Faxed Provider orders are acceptable provided they are signed, timed and dated (exceptions exist for certain outpatient diagnostic orders). 11. Caregivers have the responsibility to question any order perceived as being harmful to the patient or not perceived to be a real order. 12. Orders that are not legible will be clarified with the responsible Provider before they are carried out. 13. Radiologists may write additional orders. It is preferable that these be discussed with the ordering Provider. All additional orders, including the justification/medical necessity for ordering the procedure, must be documented in the medical record and signed and dated appropriately. 14. Standing orders must be approved by the Medical Staff and do not require a Provider s approval prior to initiation. See Standing Orders Development and Approval Policy. 15. All Provider orders must be reviewed by a Provider and continued or discontinued when a patient is transferred from one level of care to another (e.g., to or from Intensive Care Units, and/or pre and post surgery). Orders written prior to surgery that are to be resumed after surgery are to be re-ordered after surgery. Orders to resume care are not acceptable. 16. If a Provider refuses to authenticate an order after an intervention has been done, the applicable facility chain of command will be followed. 2

3 17. Late entries of Provider orders are discouraged but will be accepted. B. Inpatient and Observation Orders 1. All inpatient admissions require an admission order that clearly specifies admit or admission to. 2. Orders to place a patient in Observation or Extended Recovery should be consistent with the Compliance: Outpatient Status: Observation and Extended Recovery policy. If the order is inconsistent with the policy, the order will be clarified with the responsible Provider. 3. Transfer of a patient s care to another Provider requires an order. 4. Patients shall be discharged only on the order of the attending or covering Provider, except where the patient leaves against medical advice. 5. Inpatient, Observation and Extended Recovery orders may be written/documented by appropriately credentialed Providers. Countersignature/counter authentication may be required for orders placed by Allied Health Professionals, House Staff, or other Provider types. These requirements are defined in the applicable facility Medical Staff Rules and Regulations and/or policies. 6. A continue patient meds as at home order is not acceptable. 7. Telephone and verbal orders are acceptable per applicable policy or as approved by Medical Staff rules. Exception: Verbal/Telephone orders are not acceptable for chemotherapy, but are acceptable for dose modifications. 8. Telephone and verbal orders may be dictated to one of the following practitioners, within their scope of practice, who must document and then read back the order to the Provider for verification prior placing the order: a. Nursing telephone/verbal orders are taken only by registered nurses or licensed practical nurses and may include any type of orders except chemotherapy. b. Pharmacy telephone/verbal orders are taken only by licensed pharmacists and are limited to medications and medication monitoring (e.g.: gentamicin serum level). c. Respiratory telephone/verbal orders are taken only by licensed respiratory care practitioners, and are limited to respiratory care modalities. d. Scribes may transcribe orders under the direction of a licensed Provider per approved policy. e. Other practitioners: physical therapist (limited to PT orders); occupational therapist (limited to OT orders); speech pathologist (limited to ST orders), Laboratory (limited to Lab orders), Radiology technologists (limited to radiology orders) and dietitians (limited to Nutritionrelated orders). f. Other non-clinical hospital personnel: health unit secretaries may convey and/or transcribe telephone/verbal orders for admission/place in observation or extended recovery and bed type, transfers, or other similar communication orders. 9. Transcription of orders may be performed by the appropriate clinician for the appropriate orders. All transcribed orders must include date and time of transcription. 10. In EMR facilities: all handwritten and paper-based orders are scanned and entered into the patient electronic medical record in accordance to the applicable HIMS policies. During downtime, all handwritten and paper-based orders are checked by the RN and verified on the order sheet with date, time and signature prior to implementation. Orders electronically entered by the prescribing practitioner are checked by the RN via the electronic medical record. 11. The ordering Provider must authenticate automatic Therapeutic Substitution Clarification orders if required by applicable facility specific policy. C. Outpatient Orders: (Excludes Observation and Extended Recovery Patients) 3

4 1. A valid order must be received prior to performing any outpatient procedure, test or service. It is the responsibility of the ancillary department performing the service to ensure all elements are present. These include: patient name, date, service to be provided, reason for service (i.e. diagnosis or condition that supports medical necessity) and ordering Provider signature. Exceptions include: patients requesting screening mammograms and cardiac and pulmonary phase 3 patients. A Provider order is not required for the provision of services that are provided to the community at large or for direct access testing (e.g. Wellness Health Fairs, Cardiac Scoring, screening mammograms) 2. Verbal orders are discouraged to initiate any outpatient service. 3. Telephone orders are acceptable in stat situations when the Provider may not be in the office or is otherwise unavailable to send a copy of the order to initiate any outpatient service. a. Telephone orders must be documented in the patient s medical record and arrangements must be made by the scheduling department as to when the written order will be received or when the Provider will be available to authenticate the order. 4. Orders for outpatient diagnostic and therapeutic procedures are acceptable from licensed Providers that are within their scope of practice and as permitted by applicable state law and hospital policy. In Arizona, orders for outpatient diagnostic and therapeutic procedures may be accepted from physicians licensed in any state and from practitioners licensed to practice in Arizona. Exceptions exist based on applicable policies. 5. Orders written or initiated by Providers licensed outside the United States (Mexico, Canada) will not be accepted. 6. Orders for outpatient invasive procedures and infusion therapies will be accepted based on applicable hospital policies. Acceptance of an order may be based upon additional patient care needs with consideration of the patient s clinical condition and whether a licensed practitioner can assume responsibility for follow up treatment resulting from the order. a. Orders must be dated and signed by the ordering Provider. b. Orders signed by office personnel and stamped orders will not be accepted. c. Electronically signed orders are acceptable and will contain date and time stamps and include printed statements (e.g., 'electronically signed by' or 'verified/reviewed by') followed by the practitioner s name and preferably a professional designation. d. Orders must be activated within 60 days of the date of the signed/authenticated order and are valid for the length of the ordered therapy or 12 months, whichever is shorter. 7. Orders must include information about the medical necessity or clinical indications for the service or procedure. A narrative description of medical necessity is preferable over ICD codes. However, if a code is provided and it is deemed to be a valid ICD code, it will be used in the absence of a narrative description. Orders to rule out [X]" are not sufficient. a. When the diagnostic reason for the service or procedure is not available and the referring practitioner is unavailable to provide such information, it is appropriate to obtain the information directly from the patient. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring practitioner. 8. Scheduling: Central Scheduling or specific department may receive telephone requests to schedule the test/procedure. Except as previously stated, written orders are required prior to the test/procedure being performed. Results Reporting: Results will be reported to the ordering Provider and to any other Provider designated on the requisition/order form to receive copies of the results in accordance with the applicable facility s reporting process. 9. For recurring visits, orders should be scanned into the EMR for each new account. a. This information is addressed in the Banner Recurring Patient policy. b. Verify the order is written to meet the requirements of the new account. 4

5 c. Unless otherwise specified on the order, for recurring accounts there is no specific date in which the order will expire. If there is a change in the patient s condition which warrants a change in treatment, a new Provider order is required. 10. Faxed or original signed orders are acceptable provided all required elements are present and may be provided in any of the following formats: a. Prescription forms b. Referral forms (can be payer specific) c. Order sheets d. Outpatient Scheduling Forms e. Office letterhead f. Office history and physical or progress notes including clear indication that an order is contained therein. g. Medical Staff approved pre-printed order forms D. Order Sets: 1. Pre-printed orders are acceptable for outpatient services as described above or when the computer order entry system is unavailable for inpatients in EMR facilities. Pre-printed orders may be acceptable for inpatient admission orders in rare circumstances when necessary to initiate patient care before the ordering practitioner arrives on the facility campus. 2. When pre-printed orders are used, they must be authenticated according to the applicable Medical Staff Rules and Regulations and/or policies. E. Order Types in CPOE: 1. Written a. Used for placing orders with a signature on paper. b. Used when placing orders during the recovery process after computer downtime. c. For those facilities with PeriBirth, OB HUC/HUS/BA will continue to enter orders into Cerner based on what the Provider has entered in PeriBirth. d. Used by any Outpatient non-cpoe settings. e. Note that any written orders and prescriptions must be scanned into the medical record f. Selecting Written will not send the order to the Provider s electronic inbox for review. 2. Verbal with Read-back a. Used when clinicians receive a verbal order from a Provider. b. Providers are expected to place the majority of their own orders, so using this option should be relatively rare. c. Verbal with read-back should only be used by approved clinicians within their scope of practice. d. To make a correction or change to an order entered by a Provider, and if the Provider s intent is unknown, contact the Provider to clarify, and then use Verbal with Read-back as the communication type. e. Selecting Verbal with Read-back will cause the order to be sent to the Provider s electronic inbox for review. 3. Co-Sign Required a. Used for any standing, protocol, or nurse discretionary orders determined and agreed upon by the facility and department that has not been pre-authorized for use for the specific patient. b. This option should only be used for this scenario. c. Or as otherwise required by the facility/medical staff. d. Will send the order into the Provider s electronic inbox for review. 4. No Co-Sign Required 5

6 a. Used for orders which do not require a Provider s signature, such as nurse communication and most supply orders. Durable medical equipment always require a Provider s signature. b. Used for any standing, protocol, or nurse discretionary orders determined and agreed upon by the facility and department that has been pre-authorized for use by a Provider for the specific patient (e.g. authorization order placed upon admission to use any order in the Emergency Response Standing Orders as applicable. If an order was initiated under the Emergency Response order set, use No Co-Sign Required ). c. Used when the Provider s intent is known and additional orders are needed to carry out the original order (e.g. Provider s original order states draw blood cultures x2 if temp exceeds. If blood culture orders are entered, use No Co-Sign Required ). d. Used when the Provider s intent is known and a correction or modification is required to an already existing order. Place a comment on the order to indicate why the correction was made. Note: If the Provider s intent is unknown, contact the Provider and select Verbal with Read-back for communication type. e. Will not send the order into the Provider s electronic inbox for review. IV. Procedure/Interventions: A. N/A V. Procedural Documentation: A. Document: 1. Provider order 2. Transcription of orders 3. RN review of orders VI. Additional Information: A. N/A VII. References: A. Policy 2747: Compliance: Basic Requirements for Third Party Billing: Prohibited Billing Practices B. CMS Conditions of Participation C. Facility-specific Medical Staff documents including Rules and Regulations and Policies D. Facility-specific policies related to accepting Provider orders VIII. Other Related Policies/Procedures: A. STAT, NOW, & ASAP Medication Orders: Pharmacy Services Policy #3667 B. Medical Record Forms and External Documents, Policy # 9697 C. Administrative Closure of Incomplete Medical Records, Policy # 6036 D. Compliance: Outpatient Status: Observation and Extended Recovery, Policy #7392 E. Recurring Visits-Registration, Authorization and Medical Record Flow, Policy #7352 F. Provider Hospital Orders- Standing Orders Development and Approval Policy #11695 G. Admission Time for Hospital Inpatient Status, Policy #4116 H. Medication Orders Policy #3656 I. HIMS Scanning of Documents Policy #3280 J. HIMS Processing of Documents Policy #3009 K. Medical Record Documentation Policy #678 L. Basic Requirements for 3 rd Party Billing; Prohibited Billing Practices Policy #2747 M. Excluded Staff Practitioner Policy #2861 N. Scribes in the Emergency Department for Independent Physicians Policy, #

7 IX. Keywords and Keyword Phrases: A. Medical Orders: Accepting, Transcribing, & Signing Off B. Signing Off Orders C. Accepting Orders D. Transcribing Orders E. Noting Orders F. RN review X. Appendix: A. N/A 7