Review your Medical Staff Bylaws and other policies to
determine if they need revision to properly
address the following:
That each patient receive a history and physical examination completed
no more than 30 days before or 24 hours after admission and
documentation be placed in the patient’s medical record within 24
hours of admission.
practitioners no longer have to be granted the privilege to conduct a
medical history and physical examination by the medical staff.
other qualified individuals could complete the history and physical
examination in accordance with State law and hospital policy.
when verbal orders are used, they are to be used infrequently, and be
accepted only by persons authorized by hospital policy and procedures
consistent with Federal and State law.
When verbal orders are used they are to be used infrequently and
surveyors will expect to see action taken to facilitate this.
All verbal orders must be authenticated based upon Federal and State
law. If there is no State law that designates a specific timeframe for
the authentication of verbal orders, then verbal orders must be
authenticated within 48 hours.
Verbal orders do not need to be signed by the ordering practitioner,
but can be authenticated by another practitioner responsible for the
care of the patient. This is a temporary permission that will expire
in 5 years on 1/26/12. Do not wait until the last minute to make the
transition
For additional detail and a copy of the amended 42 CFR chapter IV,
part 482 you may click below and download our highlighted copy of the
Provisions of the Final Regulations.
CMS-3122-F,
entitled "Hospital Conditions of Participation: Requirements for History
and Physical Examinations; Authentication of Verbal Orders; Securing
Medications; and Postanesthesia Evaluations," was released 11/27/06.
