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Documentation Requirements

Please do not comit to doing this assignment unless you know about medical coding and Health Information Management.
Your hospital is reviewing its medical staff rules and regulations. As the Director of the HIM department, you have been asked to work with the physician Chairperson of the Health Information Committee to make a recommendation regarding a policy on authentication, dating and timing of physician orders, including verbal, telephone, ELECTRONIC, and handwritten orders. The policy you develop must allow the hospital to be in compliance with the documentation requirements of the Joint Commission, CMS Conditions of Participation and the State Licensing regulations.


Research and examine the documentation requirements in each of the following standards related to physicians’ orders for an acute care inpatient facility, including authentication, dating, and timing of orders:
Illinois State licensure rules (www.ilga.gov)
Click on Subpart L Records and Reports
Click on and Review SECTION 250.1510 Medical Records
CMS Conditions of Participation
Review the CMS Conditions of Participation provided by your instructor.
482.24 Medical Record Services
The JCAHO standards
Review the Joint Commission Standards provided by your instructor.
Prepare a 2-3 page report describing, comparing and/or contrasting the specific standards that apply to the authentication, dating and timing of physician orders, and make a recommendation as to what the policy for your hospital should be.

In order to be in compliance with more than one set of standards the hospital must comply with the strictest standard of the three.

Example of One Way to Approach the Assignment Regarding Verbal Orders
List each standard that applies and then select the strictest to include in your policy.

Joint Commission Standard RC.02.03.07: Qualified staff receive and record verbal orders.

Elements of Performance for RC.02.03.07 3. Documentation of verbal orders includes the date and the names of individuals, who gave, received, recorded, and implemented the orders

State Licensure Rules (IL) SECTION 250.1510 Medical Records b)Organization 5c)
Authentication of Medical Record Entries 1) All entries into the medial record shall be authenticated by the individual who made or authorized the entry.

CMS Conditions of Participation A-0454: All orders, including verbal orders, must be dated, timed and authenticated promptly by the ordering practitioner …

Analysis of the Standards: CMS has the strictest policy of the three as it requires not only dating and signing but timing as well.

Recommended Policy: All verbal orders must include the date and time of the verbal order and the name of the individual physician who gave the verbal order. All orders must be authenticated by the ordering physician within 24 hours.

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