10A NCAC 13B .3707      MEDICAL ORDERS

(a)  No medication or treatment shall be administered or discontinued except in response to the order of a member of the medical staff in accordance with policies, rules, and regulations established by the facility and medical staff and as provided in Paragraph (f) of this Rule.

(b)  Such orders shall be dated and recorded directly in the patient medical record. A method shall be established to safeguard against fraudulent recordings.

(c)  All orders for medication or treatment shall be authenticated according to medical staff and facility policies, rules, or regulations. The order shall be taken by personnel qualified by medical staff bylaws, rules, and regulations, and shall include the date, time, and name of persons who gave the order, and the full signature of the person taking the order.

(d)  The names of drugs shall be recorded in full and not abbreviated except where approved by the active medical staff.

(e)  The active medical staff shall establish a written policy in conjunction with the pharmacy committee or its equivalent for all medications not specifically prescribed as to time or number of doses to be automatically stopped after a reasonable time limit, but no more than 14 days. The prescriber shall be notified according to established policies and procedures at least 24 hours before an order is automatically stopped.

(f)  For patients who are under the continuing care of an out-of-state physician but are temporarily located in North Carolina, a facility may process the out-of-state physician's prescriptions or orders for diagnostic or therapeutic studies which maintain and support the patient's continued program of care, where the authenticity and currency of the prescriptions or orders can be verified by the physician who prescribed or ordered the treatment requested by the patient, and where the facility verifies that the out-of-state physician is licensed to prescribe or order the treatment.

History Note:        Authority G.S. 131E-75; 131E-79;

Eff. January 1, 1996;

Amended Eff. April 1, 2005; August 1, 1998;

Readopted Eff. July 1, 2020.