New canons on physicians’ orders confuse providers
A loosening of professional standards governing authentication of physicians’ verbal orders for medical record purposes has left health information managers in a quandary regarding conflicting state, federal, and professional requirements.
The Joint Commission on Accreditation of Healthcare Organizations based in Oak-brook Terrace, IL, took steps to discard rules that require authentication of physicians’ verbal orders when taken by authorized personnel such as nurses. But no such changes are expected among most states, which still require that physician verbal orders be verified in writing.
Relaxing the rules is expected to lighten paperwork and verification procedures for both outpatient and inpatient facility coders. However, the Joint Commission’s decision excludes operative reports, patient histories, or physical exams.
Meanwhile, the Health Care Financing Administration in Baltimore says it will continue to enforce its own requirements for verbal orders, while state and federal requirements will not be affected either.
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