36C24218R0169-046.pdf

RFP 36C24218R0169

D.18 EXECUTION OF PROVIDER’S ORDERS (CM 11-003, MARCH 1, 2015)

VA WESTERN NEW YORK HEALTHCARE SYSTEM

March 1, 2015 CENTER MEMORANDUM NO. 11-3

EXECUTION OF PROVIDER’S ORDERS

1. PURPOSE: To establish policy for the execution of provider orders at this healthcare facility.

2. POLICY: A plan of care, which includes provider orders, must be established for every patient accepted for care.

Patient care interventions that require an intervention by health care professionals and are outside their scope of practice require a provider’s order. Provider’s privileges determine the extent to which that individual may impact patient care (based on regulation and license). Medical-Dental By-Laws and regulations stipulate limitations within each type of practice. Medical care depends upon the prompt and proper execution of provider orders. Guidelines for execution of provider’s orders are outlined in this memorandum.

3. RESPONSIBILITIES:

A. Providers initiating orders for patient evaluation and treatment will electronically enter these orders into the Computerized Patient Record System (CPRS) component of the VISTA system. Those individuals are also authorized to enter medication orders in CPRS or on the Clinical Record (VA Form 10-1158 or 10-1158c) in the event of CPRS unavailability. Providers other than physicians or dentists may write medication orders only as delineated in their approved clinical scope of practice. (Third and fourth year medical students assigned as clinical clerks must enter the name of the ordering provider who is a member of the medical staff. The provider must sign the order for it to become active.)

B. It is the responsibility of the provider to instruct the patient on the side effects and adverse events that are possible when prescribing a new drug.

C. Services fulfilling provider orders will comply when the electronic notification of the order is received, or via the manual (back-up) system when necessary. Inpatient ward clerks will periodically check the ward default printer to ensure proper functioning and printing of Provider orders.

D. Outpatient administrative clerks are responsible for scheduling requested follow-up appointments, as ordered by Providers.

E. Outpatient administrative and nursing staff who are responsible for scheduling requested follow-up appointments, may enter laboratory orders due prior to appointment based on Provider input or Clinical Reminders due. The order must be entered via CPRS only, using the requesting provider’s name and flagged as “hold until signed.”

The order will not be released to the laboratory until electronically signed by the provider.

F. Active or expired outpatient laboratory orders already signed by Providers may be re-ordered by outpatient nurses and administrative clerks with edited dates, to facilitate timely patient care (i.e. when window of active lab order has passed). The order must be entered via CPRS only, using the requesting provider’s name and may be released without provider signature as “signed on chart” since there is already a signed order on chart requiring only editing of date. This is the only instance in which any order can be entered by outpatient nursing or administrative clerks in CPRS as “signed on chart.”

G. Inpatient ward clerks can enter/update a laboratory order as requested based on Provider input. The order must be entered using the requesting provider’s name and flagged as “hold until signed”. The order will not be released to the laboratory until electronically signed by the provider.

KEY POINT: no orders should be entered using the VISTA menu. Orders should only be entered via CPRS.

H. Outpatient requests for medication prescription renewals for medications previously written by WNY Primary Care Providers can be entered by outpatient administrative clerks and nursing staff. The order must be entered by right-clicking on the desired medication and selecting renewal, entering the requesting Provider’s name, and then flag as “hold until signed”. Requests for renewal of medication prescriptions that will not allow the above process, or for prescriptions that have been discontinued will not be entered for renewal by clinic staff, and must be forwarded to Providers for order if appropriate.

I. To facilitate timely team-based care, nursing staff may enter non-medication orders and non-diagnostic consults for Provider signature as “hold until signed” based on Provider input. These orders may only be entered via CPRS and must be electronically signed by the ordering Provider responsible for the patient’s care. The provider must sign the order for it to become active.

J. The Clinical Applications Coordinator (CAC) and the Automated Data Processing Applications Coordinator (ADPAC) for each section are responsible for providing the necessary training and implementation support about CPRS to providers as they are assigned in this healthcare facility. The CAC is the primary liaison between Administrative and Clinical Services, Care Lines, Application Coordinators, Medical Staff, Healthcare Facility Management, and the Information Systems (IS) Staff. The CAC is responsible for providing education to Administrative and Clinical Staff related to entry of orders and use of CPRS GUI. Education provided will enhance/facilitate the Healthcare Facility’s personnel in learning and adapting to new VISTA programs.

4. PROCEDURES:

A. The provider will enter all orders into the VISTA system utilizing the CPRS software. These orders will be electronically signed by the providers, utilizing the capability of the CPRS software.

B. Outpatient prescription of Schedule II through V medications by a provider requires the use of a PIV card. The NYS Prescription Monitoring Program registry (PMP) – ISTOP website will be visited prior to writing for a new or renewed controlled substance. A progress note titled “STATE PRESCRIPTION DRUG MONITORING PROGRAM” will be used to document in CPRS that the provider or designee consulted ISTOP, and will reflect any actionable findings. Use of the NYS PMP-ISTOP requires prior registration by Provider or designee health care professional who must be licensed in NYS. In the rare circumstance when a prescription for a controlled substance must be filled by a non-VA pharmacy, the provider will write the prescription on a VA prescription pad after following the procedure outlined for checking the NYS PDMP and documenting in CPRS.

C. RN staff may accept verbal or telephone orders when the ordering provider does not have immediate access to electronic order entry, or to facilitate timely care of patients. The RN may request that the order be written by Provider in person if in his/her judgment the provider should see the patient.

(1) When a verbal or telephone order is initiated the following steps will be followed:

a. All verbal and telephone orders must be entered into CPRS by the RN staff member receiving the order.

b. When taking a verbal or telephone order the RN taking the order will directly enter the order into CPRS at the time of receipt or commit the order to paper (in the event that the contingency plan is being used) so the required “read-back” process can be completed. The individual taking the order will read back the order verbatim to the ordering provider for verification of accuracy. Confirmation must be received from the provider who gave the order.

c. The order must be “released” to the respective service and the nature of the order indicated as “telephone” or “verbal”. The provider will then receive a view alert (VA) notification to sign the order. Verbal/ telephone orders must be signed by the ordering provider within 24 hours.

d. When the computer is off-line, telephone and verbal orders will be recorded on Doctor's Orders (VA Form 10-1158). Orders will be back loaded by the pharmacist as verbal or telephone order. The provider will receive an electronic view alert which needs to be signed within twenty-four (24) hours. The pharmacy can enter these back orders as signed on chart which requires no further action.

(2) Verbal and telephone orders for medications can be accepted by a RN or a registered pharmacist. It is expected that the following components of the order will be verbalized and transcribed.

a. Elements included in a verbal/telephone medication order are: date/ time, name of patient, drug name (brand or generic), dosage form (i.e., tablets, capsules, inhalants, etc.), exact strength or concentration, frequency, route, quantity and the duration, name of the ordering provider, and name and title of individual receiving the order. Only permitted abbreviations are included in verbal as well as written orders.

b. Content of verbal/telephone medication orders must be clearly communicated.

1) The name of the medication is confirmed by spelling, if necessary, for clarity.

2) In order to avoid confusion with spoken numbers, a dose such as 50 mg. should be dictated as “fifty milligrams…five zero milligrams” to distinguish from what could be heard as “fifteen milligrams.”

When writing the verbal order, the dose may be written in numerical format.

3) Abbreviations should be avoided when route and frequency are provided. (i.e., “1 tab tid” should be communicated as “Take/give one tablet orally three times daily.” When writing the verbal/telephone, standard approved abbreviations can be used.

(3) Laboratory staff members can also accept verbal or telephone orders within the scope of their professional practice and as outlined in related policies and procedures. The lab will check if sufficient and suitable specimen is available. The verbal/telephone order is read back verbatim to the provider for verification of accuracy.

Confirmation must be received from the individual who gave the order.

a. Verbal orders to “add a test” to a specimen that was previously collected is discouraged, however, when medically necessary a health care provider may add tests in the following manner. If they are the one who placed the original order, the provider may call the lab who then “adds verbal/telephone” orders into CPRS.

Verbal orders documented in the computer will prompt the ordering health care provider to sign the order electronically.

b. A provider may not “add a test” to an order placed by another provider; however, they may enter a new order (Ward Collect only).

c. Verbal orders for emergency blood requests may be initiated in a critical emergency and must follow policy and procedures outlined in Center Memorandum 113-2, Blood and Blood Product Transfusions.

d. Transfusion orders from the OR (paper SF518s are sent) need to be electronically signed by a provider as soon as possible after completion of the surgery.

(4) Verbal and telephone orders may not be given for suicide precautions, Do Not Resuscitate (DNR), involuntary admission of a patient, seclusion or physical restraints. In order to admit any person as an involuntary patient, the following procedures must be followed. An Application for Involuntary Admission on Medical Certification wherein Part A is completed and Two Physician Certifications, (filled out by two Physicians) and a

VA Psychiatrist examines the patient immediately and no later than twelve hours from the time of the first physician examination, fills out Part B of the Application prior to admission. Upon completion of part B, a Psychiatrist will provide the veteran with a copy of the Notice of Status and Rights and Involuntary Admission on Medical Certification.

D. In Batavia, the electronic signing of the orders prompts the printing of the paper “Chart Copy” of orders, which alerts the clerical and nursing staff that new orders have been entered. The Ward Clerk is responsible for acting on the appropriate orders; this alerts the RN that new orders require his/her electronic verification. In Buffalo or areas where the electronic monitor in the nurses’ station lists patient’s names with active orders to be reviewed by the RN (referred to as the Bingo Board).

E. Providers are responsible for verbally alerting the nursing staff that he/she has placed a “Stat” or “Now” order, to ensure timely execution of the order.

F. During periods when the VISTA system is down, the orders process will revert to the manual system of utilizing the Doctor’s Order form, VAF 10-1158. The procedure for this process is outlined in Network Memorandum 10N2-188-04 Network 2 Electronic Medical Record (EMR) Contingency Plan, 10N2-161-04 Network 2 Bar Code Medication Administration (BCMA) Contingency Plan and Center Memorandum 11-86.

G. If the order appears erroneous or inappropriate, questions or concerns will be directed to the ordering provider. If a satisfactory answer is not obtained and cause for concern still exists, a physician at a higher supervisory level will be asked for confirmation. If the order is confirmed by a physician at a higher supervisory level, i.e. Medical or Surgical Manager, compliance with the order is expected. If the order is not confirmed, then the Manager must contact the ordering provider for discussion and resolution. Resolution at the Manager level is expected. Unresolved issues should be discussed with the Chief of Staff.

5. REFERENCES: Network Memorandum 10N2-188-04: Network 2 Electronic Medical Record (EMR) Contingency Plan; Network Memorandum 10N2-115-11: Health Information Documentation Standards; Network Memorandum 10N2- 161-12: Bar Code Medication Administration (BCMA) Contingency Plan; CM 11-86, CM 119-09: Prescribing, Transcribing and Verification of Medication Orders; CM 119-12: Regulation of Controlled Substances Schedule II-V;

CM 113-2: Blood and Blood Product Transfusions; CM 113-13: Guidelines for Collection, Handling and Transport of Laboratory Specimens; CM 116A-12 Admission, Retention and Commitment of Psychiatric Patients; CM 116-01A Management of Suicidal Patients in Inpatient Units; Article 9, Mental Hygiene Law Memorandum entitled “Admission, Retention and Treatment Procedures for Department of Veterans Affairs Medical Centers in New York State dated May 25, 1989 from Paul Errera, M.D., Director, Mental Health and Behavioral Health Services; Joint Commission Accreditation Manuals and National Patient Safety Goals.

6. RESCISSION: Center Memorandum No. 11-3 dated October 1, 2014

7. AUTOMATIC REVIEW DATE: March 1, 2018

8. FOLLOW-UP RESPONSIBILITY: Chief of Staff (11)

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BRIAN G. STILLER

Medical Center Director

DISTRIBUTION: 1 copy each (00, 00QM, 11)