Ministry of Health

King Saud Medical City

Total Quality Management
Riyadh, Kingdom of Saudi Arabia
ADMINISTRATIVE POLICY AND PROCEDURE(APP)
POLICY OWNER: Quality & Patient Safety Improvement Council/TQM
POLICY TITLE/DESCRIPTION:
POLICY NUMBER AND VERSION:
Telephone, Verbal, and Written
APP-KSMC-070-(V4)
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
APP-KSMC-070-(V3)
REVISION DUE: 22 Sept. 2018
NUMBER OF PAGES: 9
APPLIES TO: All Departments and Employees of King Saud Medical City involved
in Telephone, Verbal and Written Orders for Medication.
1. STATEMENT OF PURPOSE:
To describe the process for accepting and taking verbal or telephone medication
orders and to prevent errors in communication.
2. DEFINITION(S):
2.1 Verbal Orders - these are orders communicated verbally and directly, by the
authorized physician initiating the order to an authorized member of the nursing
or clinical staff in an event of an emergency.
Verbal orders are to be used in situations that prevent the authorized individual
from entering the order within the required time frame, such as emergency
situations.
2.2 Authorized Prescribers- are categories of individuals that are accredited by
the hospital:
2.2.1 Physicians
2.2.2 Dentists
2.2.3 Surgeon
2.3 Telephone Orders - are orders given/communicated by the authorized
physician initiating the order to a nurse or clinical staff(authorized/
receiving staff) while the physician is outside that area. Maybe outside
the hospital or inside the hospital but is allocated in different area. Phone
orders should only be used when the ordering individual is unable to directly
enter the order within the required time frame, the order has to be signed by
ordering physician within 24 hrs.
2.4 Prescription Drug is a licensed medicine that is regulated by legislation to
require prescription (written) before it can be obtained.
2.5 Medication Error any preventable event that may cause or lead to
inappropriate medication use or harm to the patient.
2.6 Emergency a life threatening situation, such as an acute change in vital signs
or patient status that will result in rapid deterioration if not treated immediately.
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Ministry of Health
King Saud Medical City
Total Quality Management
Riyadh, Kingdom of Saudi Arabia
ADMINISTRATIVE POLICY AND PROCEDURE(APP)
POLICY OWNER: Quality & Patient Safety Improvement Council/TQM
POLICY TITLE/DESCRIPTION:
POLICY NUMBER AND VERSION:
Telephone, Verbal, and Written
APP-KSMC-070-(V4)
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
APP-KSMC-070-(V3)
REVISION DUE: 22 Sept. 2018
NUMBER OF PAGES: 9
APPLIES TO: All Departments and Employees of King Saud Medical City involved
in Telephone, Verbal and Written Orders for Medication.

2.7 Critical state- pathological state which is considered to be life-threatening

unless something is done promptly and for which some corrective action could
be taken.
2.8 PRN the medication that must be administered to the patient when needed or
when necessary as soon as possible after the STAT order.
3. EQUIPMENT/MATERIAL/FORM(S):
3.1 Patients Medical Record (PMR)
3.2 Physicians Order Form
4. POLICY STATEMENT(S):
4.1 It is the policy of the organization (King Saud Medical City) never to allow
verbal or telephone orders for the purpose of medical staff practitioners
convenience only.
4.2 Whenever possible and practicable, all members of the medical staff with
privileges and approval to prescribe medication will do so by physically entering
an order in the patients medical record, and electronically onto the computer.
4.3 Physician verbal and telephone orders shall be utilized only in emergency
situations (life threatening) and in situations where the ordering physician is
not available to write the order and delay will result in compromised patient
care. Every effort will be made to minimize the use of verbal orders. No high alert
medications shall be ordered verbally or by telephone such as ,chemotherapy drugs,
total parenteral nutrition (TPN).
4.4 Telephone and verbal orders for administration of medications may be received
and documented by licensed personnel [RN(Registered Nurse)/ RT(Respiratory
Therapist-for respiratory medications)/ RM (Registered Midwife)] lawfully
authorized to administer drugs. Such orders prescribed verbally or by telephone,
are to be issued in the best interest of the patient and therefore will be kept to a
minimum. Telephone and verbal orders for medication may be prescribed in the
following instances:
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Ministry of Health
King Saud Medical City
Total Quality Management
Riyadh, Kingdom of Saudi Arabia
ADMINISTRATIVE POLICY AND PROCEDURE(APP)
POLICY OWNER: Quality & Patient Safety Improvement Council/TQM
POLICY TITLE/DESCRIPTION:
POLICY NUMBER AND VERSION:
Telephone, Verbal, and Written
APP-KSMC-070-(V4)
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
APP-KSMC-070-(V3)
REVISION DUE: 22 Sept. 2018
NUMBER OF PAGES: 9
APPLIES TO: All Departments and Employees of King Saud Medical City involved
in Telephone, Verbal and Written Orders for Medication.

4.4.1The prescribing practitioner has determined that the patient is in need of

medication within a specific time frame in an urgent or emergent critical
situation and he/she is unable to physically write the order in the patients
medical record due to his/her physical location. The delay in the
administration of the medication would not be in the best interest of the
patients plan of care and treatment, therefore expedient ordering and
administration of the medication is necessary.
4.5 To prevent medication errors related to verbal/telephone orders, all individuals
licensed and approved by this hospital to receive and record (write down) these
types of orders must strictly observe the following practices (mentioned in
procedure 5.1) when performing this function.
4.6 Prohibited abbreviations shall not be used in documenting verbal orders or
telephone orders.
4.7 All verbal orders accepted by the staff member (registered nurse/midwife/RT) shall be
written down(WD), and then read back (RB) in its entirety to the prescribing
physician at the time the order is given, that the order is read back by the
receiving registered nurse/midwife.
4.7.1 Exception: In cases of cardio-pulmonary resuscitation (Code Blue)
where the order is given first before writing it down , a repeat back shall
be acceptable. Documentation & encoding of the prescribed medications
shall be done by the code blue team leader immediately after the procedure.
4.8 Telephone orders shall be written down and repeatedly read back loudly by the
RN (Registered nurse)/RT (Respiratory Therapist)/RM (Registered Midwife).
5. PROCEDURE:
5.1 Verbal and telephone order for medication:
5.1.1 Carry out verbal or telephone orders for medications from the
qualified physician , surgeon, dentist, duly licensed or authorized to
prescribe by the Saudi Commission of Health Specialties and a member
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Ministry of Health
King Saud Medical City
Total Quality Management
Riyadh, Kingdom of Saudi Arabia
ofADMINISTRATIVE
the medical staff of this
organization.
Document the order onto the
POLICY
AND PROCEDURE(APP)
POLICY OWNER: Quality & Patient Safety Improvement Council/TQM
POLICY TITLE/DESCRIPTION:
POLICY NUMBER AND VERSION:
Telephone, Verbal, and Written
APP-KSMC-070-(V4)
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
APP-KSMC-070-(V3)
REVISION DUE: 22 Sept. 2018
NUMBER OF PAGES: 9
APPLIES TO: All Departments and Employees of King Saud Medical City involved
in Telephone, Verbal and Written Orders for Medication.

physician order sheet form.

5.1.2Include the following criteria (written below) for all verbal and/or
telephone orders for medications:
a) Date and time the order is prescribed verbally or via telephone.
b) Name of the patient and medical record number.
c) Name of prescriber(name of the individual prescribing the drug and
his/her licensure (i.e. (Medical Doctor (MD).
d) Drug name (generic name of the drug)
e) Drug dosage (exact strength or concentration)/
f) Quantity and/or duration
g) Route drug is to be administered
h) Frequency of administration
i) Name and level of licensure of the individual receiving and
documenting the order.
5.1.3 Inpatient Medications prescribed as PRN must be dispensed in quantities
sufficient for 24 hours (according to frequency) unless the prescriber
determine otherwise, to ensure continuity of care and prevent patient suffering.
The order should include all elements of the prescription (i.e. diagnosis,
frequency, duration, route of administration, strength and dosage form) and
indication for PRN order.
5.1.4 The licensed nurse/midwife (approved by the medical staff of
this hospital) receives and records verbal/ telephone orders. This shall
preclude the taking of a verbal order by a specialty technician who are
not allowed by law within the scope of his/her responsibility and not
approved by the medical staff.
5.1.5 All individuals licensed and approved by this hospital to receive and
record verbal/telephone types of orders strictly observes the following
practices when performing this function. The receiver of the order must:
obtain all criteria information for medication verbal/telephone orders
listed above.(Procedure 5.1.2)

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Ministry of Health
King Saud Medical City
Total Quality Management
Riyadh, Kingdom of Saudi Arabia
1)ADMINISTRATIVE
Write down the complete
verbalAND
and telephone
order, and then read it
POLICY
PROCEDURE(APP)
back
to
the
prescriber,
receiving
confirmation
from
the prescriber that the
POLICY OWNER: Quality & Patient Safety Improvement Council/TQM
order is correct.
POLICY TITLE/DESCRIPTION:
POLICY NUMBER AND VERSION:
Telephone, Verbal, and Written
APP-KSMC-070-(V4)
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
APP-KSMC-070-(V3)
REVISION DUE: 22 Sept. 2018
NUMBER OF PAGES: 9
APPLIES TO: All Departments and Employees of King Saud Medical City involved
in Telephone, Verbal and Written Orders for Medication.

2) Read the entire order to the prescriber, spell the name of the drug or
requesting the prescriber to spell the drug if the receiver does not know
the spelling.
3) Request the generic name of the medication. If the prescriber is
unaware of the generic name for a medication prescribed, clarification
will be obtained from the pharmacy and it will be recorded on the
order.
4) Read back the frequency and/or instructions for use in the nonabbreviated format. Example: If an order is received for BID (twice
daily) frequency, the receiver will read the order to the prescriber as
to be administered twice daily, or two times per day
5.1.6 All verbal/telephone orders shall be transcribed (recorded) in the metric
system, excluding medications/therapies that use standard units such as
insulin. The word unit shall be written, rather than the abbreviation
U. For medications prescribed in micrograms, the word micrograms
will be written, rather than the Latin direction/ symbol microgram (g).
5.1.7 Document the verbal/telephone order immediately on the patients
medical record ( physician order form for medication) or, for pharmacists,
on a prescription form as appropriate.
a) Indicate either telephone or verbal order in the written record.
b) When entering verbal orders in writing, the receiving person must sign
the order in the following manner:
V.O. (Verbal Order) - (Doctors name/Clinical staff name,
ID or pager number, Title, Date, Time)
c) Sign the written record and indicate level of licensure.
d) The prescribing practitioner must sign the written record of the
telephone order within twenty fours (24) hours of giving the order, for
verbal order immediately before leaving the unit.(refer to APP-KSMC164-V3-Documentation Requirements.)
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Ministry of Health
King Saud Medical City
Total Quality Management
Riyadh, Kingdom of Saudi Arabia
5.1.8 ADMINISTRATIVE
The on call in each specialty
enters
the PROCEDURE(APP)
telephone order onto the electronic
POLICY
AND
system
during
off
shift
hours
and
weekends
and the
verbal order before
POLICY OWNER: Quality & Patient Safety Improvement
Council/TQM
the prescriber leaves the unit.POLICY NUMBER AND VERSION:
POLICY TITLE/DESCRIPTION:
Telephone, Verbal, and Written
APP-KSMC-070-(V4)
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
APP-KSMC-070-(V3)
REVISION DUE: 22 Sept. 2018
NUMBER OF PAGES: 9
APPLIES TO: All Departments and Employees of King Saud Medical City involved
in Telephone, Verbal and Written Orders for Medication.

6. RESPONSIBILITY:
It is the responsibility of the Quality Management & Patient Safety Committee, Total
Quality Management Department (Policy & Procedure Document & Control Unit),
Pharmacy Department, and the Pharmacy & Therapeutics Committee to review (every
three years) and monitor the implementation of this policy for effective compliance.
7. REFERENCES:
7.1 1Joint Commission International Accreditation for Hospital, 4th Edition, 1st
January 2011, IPSG Goal 2- Improve Effective Communication, page 36 to 37.
7.2 Central Board of Accreditation for Hospital Institutions (PH. 13 PH.13.2
Standards- Verbal Orders).
7.3 Pharmacy Department DPP-PHD-046 Verbal and Telephone Orders, 2007.
7.4 APP-KSMC-031: Medication Prescribing, November 12, 2007.
7.5 The website at www.hopkinspharmacy.org.staff meetings and departmental
newsletter.
7.6 APP-KSMC-008: Prohibited Abbreviations and Symbols, Nov.12, 2007.

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Ministry of Health
King Saud Medical City
Total Quality Management
Riyadh, Kingdom of Saudi Arabia
ADMINISTRATIVE POLICY AND PROCEDURE(APP)
POLICY OWNER: Quality & Patient Safety Improvement Council/TQM
POLICY TITLE/DESCRIPTION:
POLICY NUMBER AND VERSION:
Telephone, Verbal, and Written
APP-KSMC-070-(V4)
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
APP-KSMC-070-(V3)
REVISION DUE: 22 Sept. 2018
NUMBER OF PAGES: 9
APPLIES TO: All Departments and Employees of King Saud Medical City involved
in Telephone, Verbal and Written Orders for Medication.

8. APPROVALS:

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Ministry of Health
King Saud Medical City
Total Quality Management
Riyadh, Kingdom of Saudi Arabia
ADMINISTRATIVE POLICY AND PROCEDURE(APP)
NAME
TITLE
SIGNATURE
DATE
POLICY OWNER: Quality & Patient Safety Improvement Council/TQM
PolicyPOLICY
& procedure
POLICY TITLE/DESCRIPTION:
NUMBER AND VERSION:
Ms. Victoria G.
Section
Senior Nurse
Telephone, Verbal,
and
Written
APP-KSMC-070-(V4)
Ramirez
Coordinator
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
Patient
Safety Nurse
APP-KSMC-070-(V3)
Ms. Hazel Mary
Coordinator
REVISION DUE: 22 Sept. 2018
NUMBER OF PAGES: 9
APPLIES TO: All Departments and Employees of King Saud Medical City involved
Mr.
Mohammad
in Telephone,
VerbalPPU
andHead
Written Orders for Medication.
Altaweel
Mrs. Celina Eves
Dr. Khalid AlSiyabi

Reviewed by:

Approved by:

Dr. Baleegh Ali

Chief Nursing Officer

Chairman of
Pharmaceutical Care
Services
Chairman of
Pharmacy and
Therapeutics
Committee

Dr. Yousef Sharif

Acting TQM Director

Dr. Saif Ibrahim

Chairman of Quality
& Patient Safety
Improvement
Council

Dr. Haitham AlFalah

Chief Medical Officer

9. POLICY AND PROCEDURE HISTORY:

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Ministry of Health
King Saud Medical City
Total Quality Management
Riyadh, Kingdom of Saudi Arabia
Initial PP Version
1 APP-KSMC-070-(V1)
Dated: 15 January 2008
ADMINISTRATIVE
POLICY AND PROCEDURE(APP)
POLICY OWNER: Quality & Patient Safety Improvement Council/TQM
ReplacedTITLE/DESCRIPTION:
by Version 2 APP-KSMC-070-(V2)
Dated: 01AND
December
2010
POLICY
POLICY NUMBER
VERSION:
Telephone, Verbal, and Written
APP-KSMC-070-(V4)
Replaced
by
Version
3
APP-KSMC-070-(V3)
Dated: 15 August 2012
Orders for Medication
EFFECTIVE DATE: 23 Sept. 2015
REPLACES NUMBER AND VERSION:
Replaced by Version 4 APP-KSMC-070-(V4)
Dated: 23 Sept. 2015
APP-KSMC-070-(V3)
REVISION
DUE:
22 Sept. 2018
NUMBER OF PAGES: 9
Deleted Date:
__________________________
APPLIES TO: All Departments and Employees of King Saud Medical City involved
in Telephone,
and Written
Orders
for Medication.
Replaced by New
PP: PP No. Verbal
&Version______
Dated:
_____________

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