Verbal and Telephone

Orders

Office of Origin:
I.

POLICY 6.07.13
Patient Care
Verbal and Telephone Orders
Issued: April 2001
Last Approval: May 2011

Office of the Chief Medical Officer

PURPOSE
To specify when verbal and telephone orders may be used, how such orders are verified
and the documentation of such orders. For the purpose of this policy, authorized
providers include: Members of the Medical Staff and House Staff; dentists, podiatrists;
nurse practitioners, and physician assistants or pharmacists who have been authorized to
make verbal and telephone orders through standardized procedures and
protocols/guidelines, respectively, as approved by the Medical Staff.

II. REFERENCES
CMS Conditions of Participation
Joint Commission 2011 Comprehensive Accreditation Manual for Hospitals
Title 22, Section 70263. Pharmaceutical Service General Requirements.
California Business & Professions Code 2585-2586.8
UCSF Medical Staff Rules and Regulations, Section III, Physician Orders
Administrative Policy 6.07.06 Medical Orders
III. DEFINITIONS
Verbal orders and telephone orders: Orders for medications, treatments, interventions
or other patient care that are communicated as oral, spoken communications between an
authorized provider and an authorized recipient.
IV. POLICY
Verbal communication of orders should be limited to urgent situations where immediate
written or electronic communication is not feasible.
V. PROCEDURES
A. Receipt of Orders:
Verbal and telephone orders from authorized providers will be accepted and
entered in the Physicians Order Sheet by designated staff members. The staff
member taking the order shall record the order and read the order back to the
authorized provider and request confirmation. Designated staff members include
registered nurses, pharmacists, respiratory therapists, and registered dietitians.
Verbal and telephone orders shall be accepted by these staff members as follows:

1. Registered Nurses may receive and record verbal and telephone orders
from an authorized provider.
2. Pharmacists may receive and record verbal and telephone medication
orders from an authorized provider.
3. Respiratory Therapists may receive and record verbal and telephone
orders related to respiratory therapy from an authorized provider.

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Verbal and Telephone

Orders

POLICY 6.07.13
Patient Care
Verbal and Telephone Orders
Issued: April 2001
Last Approval: May 2011

4. Registered Dietitians may receive and record verbal and telephone

orders related to p.o diet orders from an authorized provider.
B. Responsibility / Documentation

1. All verbal and telephone orders must be transcribed, dated, timed and
signed by the authorized recipient in the patients medical record.
2. The authorized recipient must document that the transcribed verbal or
telephone order was read back and confirmed to the authorized
provider.
3. The authorized recipient may abbreviate read back and confirmed
with the initials R&C.
4. Pharmacists, respiratory therapists and registered dietitians must notify
the responsible registered nurse of any verbal or telephone orders they
transcribe.
5. Verbal or telephone orders for restraints must be counter-signed as
specified in the Medical Center Restraints policy.
6. Verbal and telephone orders must be counter-signed, dated and timed
by the prescribing provider or an authorized provider within 48 hours.
Countersignature by the prescribing physician is preferred. An
authorized provider is defined as a provider responsible for the
patients care at the time the therapy is given to the patient and/or at
the time the order is counter-signed.
C. Monitoring and Compliance

1. Compliance with countersignature of verbal and telephone orders (full

compliance defined as legibly or electonically signed, dated and timed
within 48 hours) will be audited and reported to the Medical Record s
Committee and included in the Chairs/Chiefs quarterly documentation
report.
VI. RESPONSIBILITY
Questions about the implementation of this policy should be directed to the Office of the
Chief Medical Officer at 353-2760..
VII.

RECENT HISTORY OF POLICY

Approved November 2003 by Governance Advisory Council and Chancellor J. Michael
Bishop
Revised January 2007 by Ernie Ring, Chief Medical Officer
Reviewed February 2007 by Policy Steering Committee and Strategic Leadership
Council
Approved February 2007 by Executive Medical Board, Governance Advisory Council
and Chancellor J. Michael Bishop

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Verbal and Telephone

Orders

POLICY 6.07.13
Patient Care
Verbal and Telephone Orders
Issued: April 2001
Last Approval: May 2011

Revised July 2007 by Jolene Carnagey, Regulatory Affairs, Paul Axelrod, Medical
Center Administration and Lila Param, Childrens Hospital
Revised and reviewed August 2007 by Adrienne Green, MD, Marcia Canning, Ernie
Ring, MD and Ann Williamson
Approved August 2007 by Executive Medical Board, Governance Advisory Council and
Chancellor J. Michael Bishop
Revised October 2007 by Adrienne Green, MD, Associate Chief Medical Officer
Approved October 2007 by Executive Medical Board, Governance Advisory Council and
Chancellor J. Michael Bishop
Revised May 2011 by Nutritional Services
Reviewed and Approved May 2011 Regulatory Affairs
Reviewed and Approved May 2011 Policy Steering Committee
Reviewed and Approved May 2011 Adrienne Green, Associate Chief Medical Officer
Reviewed and Approved May 2011 by Executive Medical Board, Governance Advisory
Council and Chancellor Susan Desmond-Hellman, MD, MPH.

This guideline is intended for use by UCSF Medical Center staff and personnel and no representations or
warranties are made for outside use. Not for outside production or publication without permission. Direct
inquiries to the Office of Origin or Medical Center Administration at (415) 353-2733.

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