Physician Orders - Transcription

Physician’s Orders - Transcription 

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Goal

To ensure accurate transcription of the physician’s orders.

Policy

All written physician’s orders or telephone physician’s orders must be duly noted and transcribed by licensed nursing staff.

Procedure

Written Orders:

1. Verification: Check physician’s orders for the physician’s signature, date, and time.
2. Transcription: Carefully transcribe orders as written to the Medication Administration Record (MAR) and/or Treatment Administration Record (TAR).
3. Documentation:
   • Place a bracket on the left side of the physician’s order form and extend the line across to the right side under the last written order.
   • Write "noted," sign with the first initial, last name, title, time (with a.m. or p.m. as applicable), and date (including month, day, and year).

Telephone Orders:

1. Documentation: Write on the Physician Order sheet the date and time the order is received.
2. Order Entry: Write "T.O." followed by the name of the physician giving the order and the name of the nurse receiving the order with the nurse’s title.
3. Transcription: Transcribe the order given by the physician.
4. Verification: Repeat the order back to the physician to ensure accuracy.
5. Follow-up: Follow the same documentation steps as for written orders.

References

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]