Is it legal to sign a VNA document/order for a doctor, i.e. Nurse AB for Dr. XYZ, in which it asks for a physician signature?
Nancy Brent replies:
If you are documenting a verbal order from a physician, the example in your question is a legally acceptable way to reflect the verbal order and that the named nurse is writing the order as directed by the physician. One could also simply document: Dr. XYZ/Nurse ABC, RN. Doing so lets the reader of the entry know how the order was delivered, who accepted it, and who documented it.
For this kind of documentation to be acceptable, however, additional factors must exist. The narrative for the patient should reflect the telephone conversation that took place between the nurse and the physician supporting the verbal order. Moreover, the physician should countersign the order as well within a specific timeframe, a probable requirement of the agency. The handling of verbal orders, and under what circumstances, also must be supported by the agency policies and procedures.
Another resource that must be reviewed is the Medicare/Medicaid home care regulations concerning documentation in home care. You can do so at the Home Health Agency Center Web site at www.cms.hhs.gov/center/hha.asp. Clicking on the link Regulations and Guidance will yield a wealth of information. You also can contact the CMS (Medicare/Medicaids Central Management Service) from the Web site by clicking on Contact CMS to submit questions.