QUESTION:
We have been reviewing our Rules and Regulations and are having trouble sorting out why there are different rules for verbal orders given by a physician speaking to a nurse practitioner while visiting a patient during rounds, versus a verbal order the physician gives to a floor nurse over the phone, versus verbal orders spoken as part of a dictation by the physician. Can you help us sort out the rules surrounding the verbal passage of information concerning patient care to other members of the care team? It seems like some of the rules are more stringent than others and we want to make sure we have got it right.
OUR ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
The rules surrounding the oral giving, taking, documenting, and authenticating of medical orders in hospitals are so confusing! You are not alone if you are baffled by the number of rules and white papers and clarifications that are out there speaking to these issues. As you continue with your Rules and Regulations review and try to sort these things out, we find it is helpful to consider the following factors, as this tends to help clarify why and how different verbal information is treated differently, depending on the circumstance:
- Whether the verbal information is being recorded by another individual verbatim, exactly as spoken by the physician/privileged practitioner; and
- Whether the verbal information is going to be acted upon immediately, before the physician/privileged practitioner has had a chance to review and authenticate the written note.
With those factors in mind, our observation has been that verbal ordering can be divided into three types:
Dictating/Transcribing – With dictation and transcription, an individual or piece of software (though this is generally considered risky due to speech recognition technology errors) takes verbal information from the physician or other privileged practitioner (usually a recording) and transcribes it into a written document, verbatim. The task is often not contemporaneous with the care provided by the physician (the transcription occurs later, after the physician has dictated the notes and orders). Further, the note is generally not considered final until the practitioner has reviewed the transcription, made any necessary corrections, and authenticated the document. There are few formal requirements governing the training of transcriptionists, though most hospitals require a certificate or associate’s degree.
Scribes – With the recording of medical information by scribes, a qualified individual (the scribe) generally listens to verbal information given by the privileged practitioner, decides which pieces of information are most pertinent, and then, contemporaneously with that patient encounter, records the information in the EMR, to assist the privileged practitioner in generating a complete record for medical and billing purposes. Note that scribes are not transcribing verbatim information but, rather, are listening and recording information so that they can accurately fill in necessary EMR data points (e.g., diagnosis, medications, orders for diagnostic tests, requests for consultation, prescriptions to be given at discharge). Therefore, after the scribe records the relevant information, it is expected that the privileged practitioner will review and authenticate the relevant note. The Joint Commission requires scribes working in hospitals to have a certain level of training (to ensure they are familiar with the EMR, understand HIPAA, are familiar with medical and billing information, etc.). But scribes are not required to be licensed or certified health care practitioners (though hospitals often establish such requirements for scribes and, in addition, establish specified procedures for vetting the qualifications of scribes prior to providing them authorization to provide scribe services in the hospital setting).
Verbal Orders – Finally, we come to verbal orders. Like scribes, those who take verbal orders are recording the information contemporaneously with when the physician or licensed practitioner is speaking. However, unlike scribes, when a verbal order is being recorded, it is generally expected that the order will be recorded exactly as spoken (verbatim). That is because the order is generally expected to be acted upon immediately and, in turn, it is essential that the order be correct when recorded. It is for this same reason that there is usually a limited, defined subset of individuals who are authorized to take verbal orders (as outlined by hospital policy) and the process of taking a verbal order is subject to greater regulation (the read-back requirement and expedited authentication – usually 24-72 hours after the verbal order is given, depending on state law). Hospitals have some discretion to determine who may accept verbal orders. Many allow other physicians, PAs, NPs, and nurses to accept verbal orders related to any matter related to their patient’s care. More limited practitioners (respiratory therapists, clinical pharmacists, etc.) are often limited to taking verbal orders within their specific medical area of practice.
As you can see, there really are a variety of ways that information is generated orally, but ultimately reduced to writing, in the hospital setting. Hopefully, this brief explanation helps to make sense of why particular rules, regulations, and policies may treat different types of verbal information differently. Good luck!
If you have a quick question about this, e-mail Rachel Remaley at rremaley@hortyspringer.com.