§ 211.3. Verbal and telephone orders.
(a) Verbal and telephone orders shall be given to a registered nurse, physician or other individual authorized by appropriate statutes and the State Boards in the Bureau of Professional and Occupational Affairs and shall immediately be recorded on the resident’s clinical record by the person receiving the order. The entry shall be signed and dated by the person receiving the order.
(b) Verbal and telephone orders for care, and treatment shall be dated and countersigned with the original signature of the physician, or physician’s delegee authorized under 42 CFR 483.30(e) (relating to physician services), within 72 hours of receipt of the order.
(c) Verbal and telephone orders for medications shall be dated and countersigned by the prescribing physician, or physician’s delegee authorized under 42 CFR 483.80(e), within 48 hours.
(d) Verbal orders for care, treatment or medication shall be accepted only under circumstances where it is impractical for the orders to be given in a written manner by the physician, or physician’s delegee authorized under 42 CFR 483.30(e). An initial written order as well as a countersignature may be sent by a fax or secure electronic transmission which includes the practitioner’s signature.
(e) The facility shall establish policies identifying the types of situations for which verbal orders may be accepted and the appropriate protocols for the taking and transcribing of verbal orders in these situations, which shall include:
(1) Identification of all treatments or medications which may not be prescribed or dispensed by way of verbal order, but which instead require written orders.
(2) A requirement that all verbal orders be stated clearly, repeated by the issuing physician, or physician’s delegee authorized under 42 CFR 483.30(e), and be read back in their entirety by personnel authorized to take the verbal order.
(3) Identification of all personnel authorized to take and transcribe verbal orders.
(4) The policy on fax or secure electronic transmissions.
Authority The provisions of this § 211.3 amended under sections 102, 201(12), 601, 801.1 and 803 of the Health Care Facilities Act (35 P.S. § § 448.102, 448.201(12), 448.601, 448.801a and 448.803); and section 2102(a) and (g) of The Administrative Code of 1929 (71 P.S. § 532(a) and (g)).
Source The provisions of this § 211.3 adopted August 29, 1975, effective September 1, 1975, 5 Pa.B. 2233; amended February 11, 1977, effective February 12, 1977, 7 Pa.B. 437; amended May 26, 1978, effective May 27, 1978, 8 Pa.B. 1466; amended April 23, 1982, effective April 24, 1982, 12 Pa.B. 1316; amended January 31, 1987, effective July 1, 1987, 17 Pa.B. 514; amended July 23, 1999, effective July 24, 1999, 29 Pa.B. 3999; amended December 23, 2022, effective July 1, 2023, 52 Pa.B. 8098. Immediately preceding text appears at serial pages (397592) and (329217).
Cross References This section cited in 49 Pa. Code § 42.25 (relating to orders).
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