How To Write a Verbal Physician Order?

How To Write a Verbal Physician Order? Understanding Accuracy and Compliance

Writing a verbal physician order requires clear communication and meticulous documentation; it’s all about conveying the exact treatment instructions to the healthcare team. This guide provides essential steps and best practices to ensure patient safety and compliance when issuing or receiving and documenting a verbal physician order.

Introduction: The Vital Role of Verbal Orders

In the fast-paced environment of healthcare, verbal physician orders are sometimes necessary. However, they represent a significant risk for errors and misinterpretations. Because of these risks, institutions have specific rules and regulations governing their use. Understanding how to write a verbal physician order? (or, perhaps more accurately, dictate and document a verbal physician order) and adhering to established protocols are crucial for patient safety and legal compliance.

What is a Verbal Physician Order?

A verbal physician order, also known as a telephone order, is a direct instruction given by a physician to a licensed healthcare professional (usually a registered nurse or pharmacist) regarding a patient’s treatment plan, when a written order cannot be obtained immediately. They are generally reserved for situations where immediate intervention is required. Because they involve indirect communication, they’re error prone.

Benefits of Clear Verbal Orders

While generally disfavored, well-executed verbal orders have some benefits in urgent situations. These include:

• Expediting treatment: Allows for immediate action when a written order is delayed.
• Improving patient outcomes: Facilitates timely interventions in critical situations.
• Facilitating communication: Enables direct communication between the physician and other healthcare providers.

The Process: Step-by-Step Guide

When issuing or receiving verbal orders, precision and accuracy are paramount. How to write a verbal physician order? begins with clear communication.

1. Identify Yourself and the Patient: Clearly state your name, title, and the patient’s name and identifying information (e.g., medical record number).
2. Clearly State the Order: Articulate the order precisely, using correct medical terminology. Avoid ambiguous language.
3. Repeat Back the Order: The recipient must repeat the order back verbatim to confirm accuracy.
4. Spell Medication Names: If the order involves medication, spell out the name, especially for drugs with similar names.
5. Clarify Dosage and Route: Clearly state the dosage, frequency, and route of administration for medications. Use metric measurements only.
6. Indicate Rationale (If Relevant): Briefly explain the reason for the order, if necessary.
7. Document the Order Immediately: The recipient must document the order immediately in the patient’s medical record.
8. Include Required Information: The documentation should include:
   • Date and time of the order
   • The complete order
   • The name of the physician giving the order
   • The name and title of the person receiving the order
   • A statement indicating that the order was read back and verified.
9. Physician Co-signature: The physician must co-sign the verbal order within a specified timeframe, as dictated by hospital policy and state regulations.

Common Mistakes and How to Avoid Them

Many errors in healthcare arise from problems with verbal orders. Knowing how to avoid these problems is crucial for patient safety. Common mistakes include:

• Ambiguous Language: Using vague terms like “as needed” without clear parameters. Always specify the exact parameters.
• Unclear Pronunciation: Mispronouncing medication names or dosages. Always spell out drug names and use numbers instead of “point” (e.g. 0.5 mg, write “zero point five mg,” and repeat.).
• Incomplete Documentation: Failing to record all necessary information. Always double-check the documentation.
• Lack of Verification: Not repeating back the order to confirm accuracy. Always read back verbatim.
• Delayed Co-signature: Not obtaining the physician’s co-signature within the required timeframe. Follow your institution’s policies precisely.

Technology’s Role in Reducing Errors

Electronic health records (EHRs) and computerized physician order entry (CPOE) systems play a significant role in reducing errors associated with verbal orders.

• Order Sets: Pre-defined order sets for common conditions can standardize treatment protocols and reduce variability.
• Drug Interaction Alerts: EHRs can alert providers to potential drug interactions and contraindications.
• Automated Documentation: EHRs can automatically populate certain fields, reducing the risk of incomplete documentation.

Legal and Ethical Considerations

Healthcare professionals have a legal and ethical obligation to ensure patient safety. Errors stemming from verbal orders can have severe consequences, including:

• Liability: Lawsuits for medical malpractice.
• Disciplinary Action: Loss of professional licensure.
• Reputational Damage: Damage to the healthcare provider’s and institution’s reputation.

The Importance of Institutional Policies

Healthcare institutions should have clear policies and procedures regarding verbal orders. These policies should address:

• Authorized Personnel: Identifying who is authorized to give and receive verbal orders.
• Acceptable Circumstances: Defining the situations in which verbal orders are appropriate.
• Documentation Requirements: Specifying the required documentation elements.
• Co-signature Requirements: Establishing the timeframe for physician co-signature.

Frequently Asked Questions (FAQs)

What is the best way to handle a verbal order in an emergency situation?

In an emergency, prioritize patient safety and administer necessary treatment based on the verbal order. Immediately document the order, including the date, time, physician’s name, and your name and title. Ensure the physician co-signs the order as soon as possible, adhering to institutional policy.

If I’m unsure about a verbal order, should I question it?

Absolutely! If you are unsure about any aspect of a verbal order, clarify with the physician before administering the medication or treatment. Document your concerns and the physician’s response. Patient safety always comes first.

Are there situations where verbal orders are not allowed?

Yes. Many institutions prohibit verbal orders for high-risk medications, such as chemotherapy agents. Know your institution’s policies and adhere to them strictly.

What should I do if a physician refuses to co-sign a verbal order?

Document the refusal and the reason, if provided. Report the incident to your supervisor and follow institutional policy for handling such situations. The primary goal is proper documentation and patient safety.

How soon does a physician need to co-sign a verbal order?

The timeframe for physician co-signature varies by institution and state regulations. It’s typically within 24-72 hours. Know and follow your institution’s specific policy.

What happens if a patient is harmed because of a misinterpreted verbal order?

A misinterpreted verbal order leading to patient harm can result in a medical error, potential legal action, and disciplinary measures for the healthcare professionals involved. Thorough investigation and transparent reporting are essential.

How does CPOE help reduce errors related to verbal orders?

CPOE reduces errors by eliminating the need for verbal orders in many situations. It ensures orders are entered directly into the system, minimizing transcription errors, providing decision support, and improving order legibility. It is the preferred method for order entry.

What is the difference between a verbal order and a standing order?

A verbal order is a specific order for a particular patient at a particular time. A standing order is a pre-approved set of instructions for managing a specific clinical situation, often for a group of patients. Standing orders require institutional approval and protocols.

How do I document a verbal order correctly in the medical record?

Document the date, time, full order details, name of the prescribing physician, your name and title, and a statement that the order was read back and verified. Accuracy and completeness are paramount.

Is it acceptable to receive a verbal order from a physician’s assistant (PA) or nurse practitioner (NP)?

The permissibility of receiving verbal orders from PAs or NPs depends on state regulations, institutional policies, and the scope of practice for the provider. Verify that they are authorized to give such orders according to applicable guidelines.

What if the physician gives me a verbal order that I believe is incorrect or inappropriate?

Voice your concerns to the physician, documenting them carefully. If the concerns persist, and you believe the order could harm the patient, follow the chain of command and notify your supervisor. Patient safety is your priority.

How often should healthcare professionals receive training on verbal order procedures?

Regular training on verbal order procedures is essential to maintain competence and compliance. Institutions should provide initial and ongoing training to all relevant staff. The goal is to minimize risks associated with verbal order communication.