Verbal Read-back

Nurses Safety

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I am trying to find the Federal and California State law for verbal read-back orders. I work in a acute care hospital in California where we take verbal orders from the physicians for procedures. It has always been drilled in my brain to "read-back" the order, but where can I find the actual JHACO regulation on this topic?

Not sure why I can't find this information.

Thanks for your help-

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

It's JCAHO (actually, it's now just JC) and I don't think it's under the purview of Joint Commission or state law, but rather each individual facility's policy. Our facility does not allow verbal orders, period, except in the case of a COR.

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Thanks for your response. I believe it was revised and updated in the JC regulations 2004..I can't find it!

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Specializes in OR, Nursing Professional Development.

Like klone said, refer to your facility policy. I am unsure whether a JC or federal policy exists, and if they do, facility policy may be more strict. The only acceptable reasons to take verbal orders where I work include: code/rapid response, traumas, and urgent orders from a surgeon who is scrubbed. Telephone orders are permitted only if the physician is unable to log into the EMR from where they are (and as most have smartphones…). In order to reduce errors, verbal and telephone orders are discouraged in many of my local facilities, and I would not be surprised if this trend is much much more common.

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I work in an area where procedures that require RN's qualified to give conscious sedation-for every procedure. Verbal orders is all we take. The recovery are has specific order sets. During procedures, you never know what the total amount given will be until the procedure is done.

Thanks for your input and if you have any other suggestions: ie;where to find the info.

Thanks-

Melissa

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

But you do know you will be giving a specific med, right? Can't you have standing written orders such as "titrate to appropriate level of sedation not to exceed x ml/kg" or something to that effect?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

The JC wants verbal orders kept to a minimum and a specific policy about who and where these orders are taken and the authentication of those orders.

RC 02.03.07

  1. The organization identifies, in writing, the staff who are authorized to receive and record verbal orders, in accordance with law and regulation.
  2. Only authorized staff receive and record verbal orders.
  3. Documentation of verbal orders includes the date and the names of individuals who gave, received, recorded, and implemented the orders.
  4. Verbal orders are authenticated within the time frame specified by law and regulation. Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: If there is no state law that designates a specific time frame for authentication of verbal orders, the verbal orders are authenticated within 48 hours. Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: In some instances, the ordering practitioner may not be able to authenticate his or her verbal order (for example, the ordering practitioner gives a verbal order that is written and transcribed, and then he or she is “off duty” for the weekend or an extended period of time). In such cases, for a temporary period expiring on January 26, 2012, it is acceptable for another practitioner who is responsible for the patient’s care to authenticate the verbal order of the ordering practitioner.
  5. For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of verbal orders includes the time the verbal order was received.

Verbal/Telephone Order Authentication and Time Frames (Updated)

[h=3]Joint Commission Update[/h]

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Specializes in Critical Care.

The Joint Commission actively encourages certain practices, but they aren't regulations or laws just because it's a JC rule since it's not a government agency or a group who otherwise has the ability to make regulations or enforce laws.

I've never worked anywhere that the MD writes the order in the situation you describe, I'd actually prefer they don't. Typically when we do a procedure in the ICU for a patient who doesn't already have sedation meds ordered, I keep track of how much I give during the procedure, then write "EGD sedation totals: Fentanyl 100 mcg IV, midazolam 3mg IV", pharmacy puts that into the EMR and then I chart to it.

I have had MD's try to be helpful before and write the sedation totals in their post-procedure totals, only to write the wrong total which then leaves me having to sort that all out.

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Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
Our facility does not allow verbal orders, period, except in the case of a COR.

Does your facility allow telephone orders?

Ps what is COR?

thx!

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I work in an area where procedures that require RN's qualified to give conscious sedation-for every procedure. Verbal orders is all we take. The recovery are has specific order sets. During procedures, you never know what the total amount given will be until the procedure is done.

Thanks for your input and if you have any other suggestions: ie;where to find the info.

Thanks-

Melissa

You won't find it. Have your practice commitee develop a set of standing protocols to cover these, and shove a copy to sign in front of any doc who wants to give you a non-emergent verbal. Make sure your medical diector is on board and s/he can enforce it c the docs.

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