TOPIC: Use a stamp to alert doctors to unsigned verbal orders
HIM Connection, November 1, 2003
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If your state regulations require authentication, unsigned verbal orders in your records is one of the quickest ways to a Type I recommendation from the JCAHO.
The staff at Ramapo Ridge Psychiatric Hospital in Wyckoff, NJ, has found a way to avoid them, according to Faye Ann Kershen, MBA, RHIA, director of health information management.
"We instituted a stamp that the nurse uses when she takes a verbal order," explains Kershen. "It's prominent enough that the next time the MD is in the orders section he can't miss it. This has helped considerably in bringing down the number of unsigned verbal orders."
The stamp consists of two bold lines about 3/4 inch apart and three inches long, according to Kershen. Under the first line are the words "MD signature." Under the second line is "date." The stamp is placed right next to the nurse's notation of the order.
Facilities in states whose regulations call for authentication of verbal orders within a specified number of hours, usually 24 or 48, should also include a space for the time the order was signed.
During a recent JCAHO survey, Kershen says the surveyor seemed focused on unsigned verbal orders. "Lucky for us, she didn't find any, but that's because we put a lot of effort into finding them ourselves," she adds.
The medical records staff checks for unsigned verbal orders after discharge, and sends them back to the doctors to be signed if necessary, says Kershen. The number and percentage of affected charts is presented to the medical staff quarterly.
"It seems like unsigned verbal orders is a hot button topic for surveyors because it's something they can detect without a lot of effort," says Kershen. "Unsigned is unsigned. It's not arguable."
This week's HIM Connection was adapted from the book, "Mastering Records Completion 2: More strategies from medical records briefing." Click here for more information or to order now and save $12.90 off the regular price.
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Sincerely,
Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com
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