Reminder: Document requirements for physician office infusion therapy medication orders

It’s important that all orders for medication, including physician office infusion therapy, are documented in a patient’s record and signed by the physician.

During recent POIT audits, many of providers overlooked the necessity of rewriting orders or co-signing verbal orders. Medication changes, which are calculated based on either the patient’s weight or condition that can result in an increase or decrease in the dosage, require an order.

Medications requiring rounding the dose up or down to the next whole unit also require an order. All medications orders must be documented in the patient’s chart with the ordering physician’s dated signature. Verbal orders must be co-signed promptly to confirm the dosage change.

Physicians’ offices referencing drug protocols or standing orders must maintain the order, with a yearly physician review, confirmed by a physician’s dated signature. When drug protocols or standing orders are used for the treatment of a patient, the document should be placed in patient’s chart and include the patient’s name.

If the document can’t be placed in the patient’s chart, a physician-signed order referencing the drug protocol or standing order must be documented in the chart. The person administering the drug must document the name of the protocol or standing order referenced in the administration record.

As specified in BCBSM Documentation Guidelines for Physicians and Other Professional Providers, “For all diagnostic and therapeutic services, the performing physician must: Document the required procedure details for each diagnostic and therapeutic service.” It also states: “The documentation for diagnostic and therapeutic services must be sufficiently detailed so that another health care professional can review the patient’s medical record and clearly understand the nature and extent of the service.”

Follow these guidelines to help avoid a potential audit recovery.