Signed and Held Medication Orders

by Jen Cowel

Signed and Held Medication Orders

by Jen Cowel

by Jen Cowel

What signed and held medication orders do you have in place today?

MM.04.01.01, EP 1 discusses the types of medication orders that are acceptable for use in your hospital. You now need written policies that both describe and authorize these orders.

Signed and Held Medication Orders

The Joint Commission added signed and held orders to this list of medication order types. They don’t require that you use signed and held orders. But if you do, a written policy should govern their proper use.

As you consider this issue, review the FAQ/Interpretation posted under the PC chapter. Use this title. “Orders – canceling and rewriting orders following a procedure or transition in care.”

Unfortunately, explanation is a little convoluted. But, TJC expects that care, treatment and services are based on two things:

  • The most recent orders
  • The most recent assessed needs of the patient

It’s common to use signed and held medication orders for post-operative. In fact, providers may write orders before conducting the procedure.

Prior to EMR technology, TJC prohibited this practice. But with the EMR, TJC has relented. The policy now says signed and held orders can be entered electronically. Also, if conditions warrant, releasing the post-operative orders is acceptable. For example, the patient’s post-operative condition is as expected.

This creates a challenge for nursing and pharmacy. Is it appropriate to release and implement the orders? What if the provider releases the signed and held medication orders after a procedure? Based on their current assessment to release those new orders. you know that the provider determined it is safe and appropriate.

But, what if the provider expects the nursing staff to release the orders upon arrival in the new care location? Then you need a formal handoff. This allows the nursing staff to know it is still appropriate to release the orders written before the procedure.

Do you intend to use signed and held orders? If so, this new rule will take some thoughtful discussion and policy development.

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Patton Healthcare Consulting assists with Joint Commission compliance assistance, CMS survey support and Joint Commission International Accreditation. Contact us for additional information.


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