How to Write a Verbal Order per Joint Commission on the Accreditation of Healthcare Organizations

The Joint Commission, formerly known as the Joint Commission on the Accreditation of Healthcare Organizations, is a private organization that works in partnership with the Center for Medicare and Medicaid Services to accredit hospitals and other health care providers. While the Joint Commission does not govern hospital licensing, its high standards for patient care and organization have made it an industry hallmark. Among its many standards and recommendations, the Joint Commission has guidelines on how and when verbal physician orders should be given in medical facilities.

Instructions

• 1

  Look for an alternative to using a verbal physician order. Joint Commission guidelines discourage the use of verbal orders. If you have no way to get a physician to write orders in person, try to obtain the order by fax or email. Verbal orders can lead to mistakes and liability for everyone involved.

• 2

  Ask to speak directly to the physician before taking down a verbal order. Joint Commission standards prefer that there be no third party involved in the transmission of a verbal order. When a physician gives her attending nurse her orders to pass on to another nurse to write down, the risk of error becomes very high.

• 3

  Write the order down. Read it back to the physician for confirmation. The Joint Commission emphasizes having the confirmation process.

• 4

  Make any corrections or additions that the physician tells you to make. Read back the final version for the physician to confirm.

• 5

  Enter the final order into the patient's chart immediately if possible. Include the date and time of the order. Do not use any abbreviations forbidden by the Joint Commission. The Joint Commission maintains a list of abbreviations that it believes can cause errors in patient care delivery and clinician communication. (See Resource.)

• 6

  Show the written order to your nurse manager or other supervisor before executing it to make sure someone else has reviewed it. If your supervisor has any concerns, call the physician back with the supervisor on the line to verify the order.