doctor's order for treatment performed by auxiliary personnel

CatchTheWind

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If auxiliary personnel perform an office service (such as giving an injection), is it enough for the auxiliary person to document that this was done at the doctor's request? Or does it have to be in a plan or order signed by the doctor?
 

thomas7331

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My understanding is that all orders, including verbal orders, must be signed/authenticated and dated by the responsible provider in the patient's medical record. Orders that aren't signed are not only a serious audit risk for the organization but also put the auxiliary staff at risk for allegations of practicing outside the scope of their license. It's important for the auxiliary personnel to cover themselves by ensuring that the physician documents and signs all orders so that in the event of an adverse outcome they would not be held liable for doing something outside the plan of care.
 

MnTwins29

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Thomas is right - the ordering physician does need to sign the order, but the person performing the ordered procedure does not need to document that this was done on order from the doctor - that is implied. The person performing the ordered procedure needs to document what was done, how much, any reactions, etc but does not need to document it was done due to the doctor's order.
 
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