FLORIDA STATE HOSPITAL STATE OF FLORIDA OPERATING PROCEDURE DEPARMENT OF NO. 151-15 CHILDREN AND FAMILIES CHATTAHOOCHEE, December 18, 2017

Medical Documentation/Records

PHYSICIAN’S ORDERS

1. Purpose: To communicate the medical care that the resident is to receive as well as document the various treatments that were ordered by the physician. It ensures that treatments are rendered in a safe, clear, timely, and efficient manner.

2. Scope:

a. Licensed Physicians, Licensed Dentists, Licensed Advanced Registered Nurse Practitioners (ARNPs) and Licensed Physician Assistants are authorized to give Physician’s Orders consistent with the treatment needs of the resident, according to established protocols, and consistent with the practice setting.

b. Physician’s orders will only be given within all applicable state and federal laws, policies and procedures of the facility and agency, and the rules and regulations of the medical staff; they shall be completed at the highest level of these accepted standards.

3. References:

a. Florida Statutes, Chapters 394, 458, 459, 464, and 916

b. Children and Families Operating Procedure 155-1, Guidelines for Psychiatric, Medical and Nursing Responsibilities with the Use of Psychotherapeutic Medications in State Mental Health Treatment Facilities

c. Children and Families Operating Procedure 155-20, Use of Seclusion in Mental Health Treatment Facilities

d. Children and Families Operating Procedure 155-21, Use of Restraint in Mental Health Treatment Facilities

e. Florida State Hospital Operating Procedure 155-22, Seclusion and Restraints Use in Psychiatric Crisis Management

f. Florida State Hospital Operating Procedure 150-34, Psychotherapeutic Medication Prescription Standards

g. Florida State Hospital Operating Procedure 150-14, Medical Restraints & Safety Devices

h. Florida State Hospital Guidelines, Medical Records Abbreviations List

i. Florida State Hospital Operating Procedure 155-11, Medication Education/Management Program

This Operation Procedure supersedes: Operating Procedure 151-15 dated December 19, 2016 OFFICE OF PRIMARY RESPONSIBILITY: Clinical Services DISTRIBUTION: See Training Requirements Matrix December18,2017 FSHOP151-15

4. Definitions:

a. Licensed Physician/Dentist: A person permitted by law to provide resident care services independently within the scope of their license and in accordance with granted clinical privileges.

(NOTE: For the purpose of this operating procedure, the term “physician” includes the dentists, advanced registered nurse practitioners (ARNP), and physician assistants/clinical associates.)

b. Attending Physician: The physician who has primary responsibility for an assigned resident; the Medical Physician for Medical Services Unit inpatients; and the Senior Dentist in Dental Services.

c. “On-Duty” Physician: The Medical Services Unit (MSU) Triage/Emergency Room (ER) Physician or Psychiatrist on call.

d. Licensed Advanced Registered Nurse Practitioner (ARNP): A person licensed to practice professional nursing; who meets Certification by an appropriate specialty board; who is authorized within the framework of an established protocol to perform certain medical duties normally reserved for physicians (such as prescribe or order drug); and who operates under the guidance of a Physician preceptor as described in Chapter 464, Florida Statutes.

e. Registered Nurse: A person licensed in the State of Florida to practice professional nursing requiring substantial specialized knowledge, judgment and nursing skills based upon applied principles of psychological, biological, physical and social science.

f. Licensed Pharmacist: A person licensed in the State of Florida to practice the profession of pharmacy.

g. Licensed Practical Nurse: A person licensed by the State of Florida to perform select acts in the care of the ill, injured, or infirm under the direction of any of the above listed licensed professionals.

h. Verbal Order: A Physician’s order given to a licensed person who is authorized to receive and record verbal orders in accordance with law and regulation. It is given when the licensed physician is physically present, but the nature of the situation does not permit the Physician to write, input or transcribe the order.

i. Telephone Order: A Physician’s order given via the telephone when the Physician is not physically present to write or input the order.

j. “Stat” = “urgent and immediate” and the medication must be administered within thirty (30) minutes after being prescribed.

k. “ASAP”, “Now” = medication must be administered within two hours after being prescribed.

l. “a.c.” = ante cibum (before meals) and “p.c.” = post cibum (after meals). Such orders shall be administered at least 30 minutes before or after meals, unless some other time is specified in the order.

5. Standards and Procedures:

a. ALL Physician’s Orders MUST:

(1) always document the specific rationale for the order. If applicable, the rationale must describe specific behavioral terms that indicate imminent or immediate danger.

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(2) be clear, precise and unambiguous; be specific with medication name, dosage, route/formulation, and frequency; and may include a time, such as a.c. or p.c. orders. Specify a formulation (i.e., such as injection, syrup, concentrate); otherwise, it will be dispensed as an oral solid.

(3) be e-Signed in HCS by the physician giving the orders by following these steps: (a) ‘Just My Orders’ (top of the screen);

(b) ‘e-Sign Selected Orders’ (bottom of screen, left corner); then

(c) ‘eSign Med Orders’ or ‘eSign Other Orders’ (bottom of the screen).

(4) be written in the appropriate Physician’s Order forms as follows:

(a) Admission orders – Physician’s Orders--Admissions Physicals form (Form 94) or Form 150 Physician's Order form.

(b) Monthly or quarterly laboratory testing – Physician’s Orders— Monthly/Quarterly Lab (Form 195) or Form 150 Physician’s Order form.

(c) ALL diet orders – Physician’s Orders—Meal, Snacks, Supplements form (Form 99). Utilize the “Other” section on Form 99 for all diet order modifications such as “finger foods,” “celery sticks to use as utensils,” etc.

(d) Restraint orders – Physician’s Restraint Order form (Form 236).

(e) Seclusion orders – Physician’s Seclusion Order form (Form 237).

b. In HCS, the ‘ADT’ Tab will be utilized for orders on Admission, Discharge and Transfers.

c. In HCS, the ‘Ancillary Orders’ Tab will be utilized for:

(1) LOA (Leave of Absence). ‘Add’; chose ‘ADT’ and then ‘ADT Transfer’. This will ‘transfer’ the resident’s name to a virtual ‘LOA Unit’.

(2) Emergency Treatment Orders

(3) Observation Orders

NOTE: Medication Exception Requests (MERs), Seclusion orders, Restraint Orders and Physician Orders for Lab Tests are still done on paper because there are no HCS apps available at this time. Paper forms for Physician’s Orders shall be utilized when the electronic system is inoperable.

d. Physician’s Orders for Lab Tests and other administrative orders:

(1) The specific name of test and the rationale for the test must be documented;

(2) Sign after the statement located at the bottom of the Physician’s Orders form which reads: “For Medicare Residents: The above ordered laboratory tests are medically reasonable and necessary.”; and,

(3) Include diagnostic information as required by Section 4317 Requirement to Furnish Diagnostic Information of the Balanced Budget Act of 1997 as in the following excerpt: “The physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.''

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e. Physician’s Orders for medical restraint are valid for up to seven (7) days, at which time they must be reordered if continuation is clinically indicated. There must be documentation of all attempts taken to remove medical restraints; the registered nurse will assess residents who require medical restraint for chronic conditions (requiring intermittent medical restraints for thirty days or more.) For example, a resident who wanders aimlessly and is unable to sit long enough to assure adequate dietary intake may require medical restraint during mealtimes only.

In units certified by Federal Regulations for Medicare/Medicaid (CMS), the Attending Physician must E-Sign to certify: “that the psychotherapeutic medications on this date are not being used: as a substitute for behavioral or other programs; as a punishment; as a means to suppress undesirable behavior; for the convenience of the staff; for experimental purposes.”

It is the responsibility of Nursing to develop internal procedures to ensure that a nurse checks the Medication Administration Record (MAR) for reorders.

f. Telephone orders are restricted to those times when the Physician is not physically present to write the orders.

(1) The nurse must input the order immediately in HCS.

(2) The order must be read back to the ordering Physician.

(3) The order must be reviewed and E-Signed by the ordering Physician by the next regular working day, not to exceed 72 hours.

(4) Telephone Medication orders may only be given to and accepted by an Advanced Registered Nurse Practitioner (ARNP), Registered Nurse (RN), Registered Pharmacist, or a Licensed Practical Nurse (LPN) except in units where Federal Regulations for Medicare/Medicaid Certification (CMS) prohibits an LPN from accepting telephone orders.

(5) Receipt of telephone orders may be witnessed by a second party for verification at the discretion of the receiving nurse. When a second nurse is not in the area, verification may be obtained through the use of the conference call system to an available nurse in another area of the hospital.

g. Verbal orders are to be used only in situations when the Physician is physically present but the nature of the situation does not permit the Physician to write or transcribe the order.

(1) The order must be input immediately in the electronic HCS.

(2) The order must be read back to the ordering Physician.

(3) The order must be reviewed and E-signed by the ordering Physician before close of business on the day the order was given.

h. Physician orders may only use those abbreviations approved under ‘Florida State Hospital Guidelines, Medical Records Abbreviations List’.

i. Orders that are not time-specific nor limited by the facility’s ‘Automatic Stop Order’ policy will be reviewed and renewed every thirty days from the date of the original order.

j. Self-administration of medication (as allowed by FSHOP 155-11 Medication Education/ Management Program) will be permitted only when directly ordered by the Physician and with the written consent of the resident, and/or the legal representative.

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k. An Advanced Registered Nurse Practitioner (ARNP), in collaboration with a supervising physician, may initiate, continue or discontinue an Emergency Treatment Order (ETO) and may prescribe a controlled substance in accordance with Florida law and within their scope of practice.

l. P.R.N. orders are permissible only for medical/non-psychotherapeutic medications.

(1) There will be NO P.R.N. ORDERS for SECLUSION, RESTRAINTS or PSYCHOTHERAPEUTIC MEDICATION.

(2) Shall terminate in accordance with the ‘Automatic Stop Order’ policy of the hospital.

m. Words such as "increase, decrease, change, add," etc., may be used in orders if it improves clarity of the order or helps to ensure accuracy. Pharmacy will automatically discontinue previously prescribed order when a new order is given for a different form or dosage of the same medication.

n. Dosing Titration: Unless emergency, dosing titration shall ‘automatically' start on the next day following the order. This is to ensure that Pharmacy has accurate Medication Administration Record (MAR) information, completes new pharmacy labels, and dispenses the medication(s) to the unit.

o. ‘Hold’ orders are for 24 hours only; beyond that, the medication(s) will be automatically discontinued.

p. Medication orders which do not comply with FSHOP 150-34, Psychotherapeutic Medication Prescription Standards Guidelines, must be processed through the Medication Exception Request (MER) process (using form CF 1582) before the Pharmacy can fill the order.

q. Physician’s Orders will be electronically signed off (E-sign) by the ordering Physician within 24 hours of the order (excluding weekends or legal holidays). In situations where the ordering Physician is unavailable to sign within 24 hours, the Medical Executive Director or appropriate Medical Service Director/designee shall sign the order.

r. ‘On-Duty’ Physician orders will be in effect for thirty days unless an order is written to discontinue/supersede the order.

6. Standardized Dosage Administration Times: daily 0800 hours (except laxatives, which are given at bedtime), unless otherwise specified b.i.d. 0800 hours and 2100 hours, unless otherwise specified (twice a day) t.i.d. 0800 hours, 1600 hours, and 2100 hours unless otherwise specified (three times a day) q.i.d. 0800 hours, 1200 hours, 1600 hours, and 2100 hours, unless otherwise specified (four times a day) 5 x daily 0800 hours, 1200 hours, 1600 hours, 2000 hours, and 2400 hours, unless otherwise specified H.S. 2100 hours, unless otherwise specified (at bedtime) p.r.n. a specified time limit or expires automatically in 24 hours – see limitations in Automatic Stop Order (as needed) Policy in the Florida State Hospital Formulary q4h 0400 hours, 0800 hours, 1200 hours, 1600 hours, 2000 hours, and 2400 hours, unless otherwise specified q6h 1200 hours, 1800 hours, 2400 hours, and 0600 hours, unless otherwise specified q8h 0800 hours, 1600 hours, and 2400 hours, unless otherwise specified q12h 0800 hours and 2000 hours, unless otherwise specified a.c. Each unit/ward to determine these times (pharmacy will type "30 minutes before meals" unless (before meals) specified otherwise, etc.) p.c. Each unit/ward to determine these times (pharmacy will type "30 minutes after meals" unless (after meals) specified otherwise, etc.)

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7. Training Requirements: A check in the box below indicates which employees within the department are required to read this operating procedure and when they will receive training at Florida State Hospital. Employees within identified departments will also be required to review the policy each time it is updated.

New Discipline Worksite Annual Department Employee Specific Education Update Orientation Training All Employees Clerical Dental X Dieticians, Laboratory, Special Therapy, X-Ray Techs Direct Care Emergency Operations Environmental Services (Aramark) Financial Services Food Services Health Information Services Human Resources Information Systems Legal Materials Management Nursing X Operations & Facilities (Aramark) Pharmacy X Physician/ARNP (Prescriber) X Professional Development Psychology Quality Improvement Recovery Planning Rehab Services Resident Advocacy/Risk Mgt. Social Services Supervisors/Managers Volunteer Services Other: Physician Assistant X

Signed Original on file in Quality Improvement Program

BOB QUAM Chief Hospital Administrator

SUMMARY OF REVISED, ADDED OR DELETED MATERIAL

This procedure was revised to include procedures for the newly implemented electronic medical records (Health Care Systems – HCS) system were included.

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