Signing and dating doctors orders


Because of this, we are alerting you to the importance of these signature requirements and if changes are needed, we suggest you take immediate action.Signature’s Requirements Medicare requires that services provided/ordered be authenticated by the author. The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to demonstrate that services submitted to Medicare have been accurately and fully documented, reviewed and authenticated.

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After complaints from AHA and other health care organizations, CMS relaxed the guidelines specifically to allow the use of standing orders in emergencies, and claims to support the use of protocols overall. Although CMS ostensibly likes the idea of standing orders, bureaucratic requirements for how orders get signed can make using the protocols very difficult.

CMS recently came to my hospital and disallowed standing orders used in the Emergency Department and in one of our ICUs.

Once the protocol was adopted, the SICU nurses could slowly -- and according to clearly delineated steps -- reduce the amount of ventilatory support patients received.

If patients began to struggle to breathe, the ventilator could be returned to its original settings and no harm done.

Editor's note: Theresa Brown is an oncology nurse in Pennsylvania.