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Verbal Orders Must Have: o Frequency with duration o Why the change/addition is being made o Identifying information: Spoke with in Dr s office.
A verbal order is acceptable only when a CPOE or written order cannot be submitted. Verbal orders are real-time oral communication between the prescriber (sender) and a licensed nurse (receiver) with the authority to receive and record transcribe the orders in the medical record.
Verbal orders include all telephone and faceto face patient care orders that (1) were communicated verbally by the ordering provider (e.g., physician, physician assistant [PA], or advanced practice nurse [APN]), (2) required transcription by the proxy (e.g., nurse or unit clerk) receiving the order, and (3) required a
CMS regulation states that verbal orders must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient. The receiver of a verbal order must date, time, and sign the verbal order in ance with hospital or clinic policy.
American Society of Hospital Pharmacists guidelines recommend that only a pharmacist or an RN accept verbal orders.
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The name, registration number and diagnosis are confirmed by the authorized doctor giving the order to ensure that the correct patient receives the correct medication. The nurse receiving the order must record the order as Verbal/ Telephonic Order.
A verbally communicated order must contain all components of a valid written order. It must also contain the name of the person who issued it as well as the name and title of the person who received the order.
Orders must include: Name of the medication/product. Strength, dosage, and frequency of the medication/product. Quantity of medication/product. Method of administration. Special instructions. Physician/Clinicians original signature within 10 days.

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