Policy Manual sample

MDT Home Health Care Agency, Inc. CONFIRMATION OF PHYSICIAN ORDERS PURPOSE: To provide care, treatment and/or services according to a state licensed physician or licensed practitioner’s orders or prescriptions in compliance with applicable laws and regulations and prevent errors. Verbal order means a physician order that is spoken to appropriate personnel and later put in writing for the purposes of documenting as well as establishing or revising the patient’s plan of care. When services are provided on the basis of a physician’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and our HHA’s policies, we must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as our HHA’s internal policies. POLICY:  The Agency provides care, treatment and/or services to patients according to a physician’s or licensed practitioner’s most recent order(s) or prescription(s).  The Agency accepts verbal/telephone/facsimile and/or written orders from physicians or licensed independent practitioners whose licenses have been verified according to Agency policy.  Orders are obtained from the physician or other authorized individual according to applicable laws and regulations and professional practice acts prior to providing care, treatment and/or services.  All orders for medical care, treatment and/or services are reviewed/evaluated for appropriateness and accuracy by an appropriately licensed individual (i.e., Registered Nurse, Licensed Therapist, Pharmacist) prior to providing care, treatment and/or services.  Orders for care, treatment and/or services should be tailored to each patient’s needs and include all elements required by law and regulation.  Care, treatment and/or services are provided according to the most recent order/prescription.  All orders are renewed or updated to reflect:  Changes in the care, treatment and/or services being provided  Changes in the patient’s physical or psychosocial conditions  The patient’s response to care, treatment and/or services  The patient’s outcome related to care, treatment and/or services  Changes in diagnosis, treatment (including procedures and medications) and equipment  Physician verbal/telephone orders are accepted by qualified staff and submitted to the physician for his/her signature within 10 days.  Original and/or new/update orders are transcribed onto a Physician Order/Prescription form or a plan of treatment form as appropriate, and mailed or faxed to the physician for signature within 10 days of days of receipt of the order by Agency personnel. Home Health Agency Nursing Manual J-58