Changes I have seen over three decades

Earnhart, Stephen W.
January 2007
Same-Day Surgery;Jan2007, Vol. 31 Issue 1, p12
Academic Journal
The Centers for Medicare & Medicaid Services (CMS) has published a final rule that affects the history & physical (H&P), verbal orders, and medication security. • H&Ps may be completed within 30 days of surgery and must be added to the record within 24 hours of admission. CMS eliminated the requirement that the H&P must be signed by someone privileged by the medical staff, but that requirement remains for facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations. • For the next five years, verbal orders must be authenticated by the prescribing practitioner or another practitioner responsible for the care of the patient. CMS expects this time period will allow technology to advance and allow prescribing practitioners to authenticate their own orders promptly. • CMS now requires that all drugs and biologicals be kept secure and locked, when appropriate, which will allow patients to keep their potentially life-saving medications with them.


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