Verbal Order Policy

VERBAL ORDER POLICY
To serve as a guiding direction for verbal ordering of the medication through

telephone.
Policy
1. When a doctor initially writes a prescription sheet, the nurse and doctor
responsible for the patient should ensure suitable PRN drugs (e.g.
analgesics, antiemetics, night sedation and any infusion liquids) are
prescribed to prevent the need for a verbal order.
2. Verbal communication of prescription or medication orders and test results
is limited to urgent situations in which immediate written or electronic
communication is not feasible.
3. Verbal orders and test results are not allowed when the prescriber is present
and the patient’s chart is available, except during a sterile procedure or in an
emergency situation, in which case a repeat-back is acceptable.
4. Verbal orders are not permitted for
 Controlled Drugs via any route for first time
 Epidural boluses
 Blood/blood products
 Hematology
 Children/Neonates
 Patients with documented history of chronic kidney disease or acute renal
failure
except during a sterile procedure or in an emergency situation, in which case a
repeat-back is acceptable.
5. Verbal orders for antineoplastic agents should NOT be permitted under any
circumstances. These medications are not administered in emergency or
urgent situations, and they may have a narrow margin of safety.
Procedures:
1. Information that should be given in a verbal order include the following:
 Name of patient
 Age and weight of patient, when appropriate
 Drug name
 Dosage form (e.g., tablets, capsules, inhalants)
 Exact strength ,dose or concentration
 Dose, frequency, and route (including the dose basis for pediatric patients)
 Quantity and/or duration
 Purpose or indication (unless disclosure is considered inappropriate by the
prescriber)
 Specific instructions for use
 Name of prescriber—and telephone number, when appropriate
 Name of individual transmitting the order, if different from the prescriber
2. The content of verbal orders should be clearly communicated:
The name of the drug should be confirmed by one or more of the

following:
 Spelling
 Providing both the brand and generic names of the medication
 Providing the indication for use
 To avoid confusion with spoken numbers, a dose such as 50 mg
should be dictated as "fifty milligrams...five zero milligrams" to
distinguish from "fifteen milligrams...one five milligrams."
 To avoid confusion with drug-name modifiers, such as prefixes and
suffixes, additional spelling-assistance methods should be used (e.g.
S as in Sam, X as in X-ray).
 Instructions for use should be provided without abbreviations. For
example, "1 tab tid" should be communicated as, "Take/give one
tablet three times daily."
 Both parties will include the mg/kg dose along with the patient’s
specific dose for all verbal neonatal/pediatric medication orders.
 The receiver of the order should write down the complete order, then
read it back, and receive confirmation from the individual who gave
the order except in situations such as a sterile environment and/or
emergencies when stating back the order (without writing the order
down first) with subsequent confirmation is acceptable.
3. The individual accepting the verbal order shall record and then read back the
order in its entirety to the prescribing physician at the time the order is
given, documenting that the order was “read back” (RB).
4. Nursing staff shall tag all verbal orders with an annotation to alert the
physician of the need to sign the verbal order upon return to the unit.
5. Nursing staff are permitted to act upon verbal orders provided the orders
contain the appropriate information.
6. Verbal and telephone orders shall be signed or initialed by the prescribing
practitioner as soon as possible, not later than 12 hours.
7. When the ordering physician is unavailable, it is acceptable for another
team member or the attending staff to authenticate the verbal order
8. Whenever there is doubt regarding a particular prescription (such as illegible
handwriting, wrongly written strength/dose or frequency, doubt regarding
similar sounding medicines, duplication etc.) or when a prescription is
incomplete ( without sign, date, etc), the pharmacist should promptly call the
doctor and inform him and get it corrected without causing inconvenience
for the patient. These are usually instigated by the Pharmacist to clarify a
prescription and make it safe. This is accepted practice. In such situations,
the Pharmacist will amend a prescription with clear annotation of the
change, the doctor's name, the Pharmacist's name and the date of the
amendment. This does not need to be countersigned by a doctor.
9. The attending nurse shall remind the treating doctor about the patients
known drug allergies as marked with red ink on the patients file so that the
patient does not receive that drug
10.The nurse receiving the verbal order takes responsibility for that order.
Every nurse has the right to refuse to take a verbal order. Any problems that
arise must be referred to the nurse in charge of the shift. If they cannot be
resolved easily, the Senior Nurse, Director of Nursing or Medical Director
must be involved.

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VERBAL ORDER POLICY

To serve as a guiding direction for verbal ordering of the medication through

2. The content of verbal orders should be clearly communicated:

The name of the drug should be confirmed by one or more of the

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