KADLEC MEDICAL CENTER



KADLEC MEDICAL CENTER

HOUSE-WIDE

Section: Corporate Compliance

POLICY AND PROCEDURES

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|AUDIT REVIEW: (By and Date) |

Purpose: To ensure appropriate diagnostic studies and therapeutic services are provided to patients referred to Kadlec by authorized licensed practitioners.

Policy:

Outpatient diagnostic studies and therapeutic services may be provided only in accordance with an order written by an appropriately licensed practitioner. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician/practitioner who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem.

Mammography exception. Radiologists who interpret screening mammographies are allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam.

All orders must include the following five elements:

➢ Date of order

➢ Patient name

➢ Test or service being ordered

➢ Diagnosis or reason for service

➢ Physician (or other licensed practitioner) signature

Date of Order – If the written order is presented without the date completed, the clerk may verify the date with the physician’s office and fill in the information as indicated.

Patient Name – Patient name should be complete. If the patient name is incomplete or misspelled the clerk may complete or correct per patient indication.

Test or Service being ordered - Orders shall be specific and complete. The staff of the hospital has the right and the obligation to question any order that is illegible, ambiguous or incomplete.

Diagnosis or reason for test - Referring physicians are required to provide diagnostic information to the hospital at the time the test is ordered. Diagnosis or reason for service should not include the following terms: probable, suspected, questionable, or rule out. If diagnosis is not yet determined, signs or symptoms should be used. If an order for service includes these terms, hospital personal will contact the ordering physician for clarification. If the written order is presented without the reason or diagnosis completed, the clerk may verify the information with the physician’s office and fill in the information as indicated.

Physician Signature- Kadlec requires physician signature to authenticate all orders for outpatient diagnostic or therapeutic services. Upon request, this requirement may be waived for electronically generated orders if it is determined by the hospital that appropriate security measures are in place.

Verbal or telephone orders are those given orally by a physician to a licensed health care professional. Registered and licensed Practical Nurses may take verbal or telephone orders related to all aspects of patient care. In outpatient departments, verbal orders shall be considered to be in writing if dictated to licensed staff functioning within their area of expertise. Verbal and telephone orders should be used infrequently and at the discretion of the department director.

In departments that allow verbal orders the following procedures must be followed: These orders shall always be read back to the originator to verify accuracy. The five required elements of an order must be complete. The receiver’s full name and title shall follow the transcribed order. The responsible physician or covering physician shall authenticate verbal orders within 30 days. Designated department representative will be responsible for obtaining the physician’s signature to authenticate the order. If authentication is not received in 30 days (or as defined in Medical Staff Rules and Regulations) a copy of the order will be forwarded to the Director of HIM for follow-up and possible physician sanctions.

Revision or Clarification of Order

If the ordering physician submits an order that includes unclear or incorrect information, hospital staff is obligated to question the ordering physician and to revise the order as directed by the physician. (i.e. correction to diagnosis or date) Documentation to alter the order must be maintained with the original order. The documentation may be written information from the ordering physician or a written note documenting the telephone call with the ordering physician. A faxed copy of the documentation is acceptable.

Mammography Exception:

Self-Referred Screening Mammogram - Screening mammography is a radiological procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician's interpretation of the results of the procedure. Medicare allows for self-referred screening mammograms based on age and frequency requirements. Patients presenting for self-referred screening mammograms will be requested to provide a personal physician name for results but no order is required. This requirement also applies to Kadlec employee screening mammograms.

Outpatient Rehab Exception:

Speech Therapy, Massage Therapy and Physical Therapy may be self-referred under Washington State Law. Kadlec accepts self referrals for these services.

WAC 246-320-385 Outpatient Care Services

WAC 246-320-205 Management of Information

42 CFR Conditions of Participation for Hospitals §482.24(c)(1) Medical Record Services

42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions

42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests (a)(2) Mammography Balanced Budget Act §4317(b)

21 CFR 900 Subsection B (2)

CMS HIM 10 §451(G)

JCHO FAQ’s Authentication of Documentation

Kadlec Medical Center, Medical Staff Rules and Regulations §(2)

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