C-11-320 Order Management: Reviewing Received Orders

👤 ROLE

Medical Records Specialist

🎯 PURPOSE

This process identifies essential steps that must be taken by the Medical Record Specialist when processing orders received from a Physician/Non-Physician Practitioner (NPP) and gives precise instructions to ensure detailed review of received orders including appropriate follow-up and escalation of any notations found as well as verification of valid Physician/NPP signature and date.

🔄 PROCESS

After an order has been sent from the home health agency to a Physician or Non-Physician Practitioner (NPP) for signature, the Physician/NPP will return the order signed and dated. However, before an order is processed as valid and linked to a client’s chart, the order must be thoroughly reviewed to ensure any marking or notation from the Physician/NPP is escalated to the appropriate person(s) and that the required criteria are met including valid signature and date.

1. When an order is received via fax, it will arrive in Mosai for review and processing.
   • If an order is received by an alternative method (such as mail), the same standards of review, verification, follow-up and escalation apply.
2. During initial review, the Medical Record Specialist must scrutinize the order, page by page, to identify any of these items:
   • Any marking or notations from the Physician/NPP’s office
   • Any missing pages or portions of pages cut off
   • Unacceptable fax quality (blurriness/illegibility)

3. If the quality of the fax is not acceptable, or if there are pages missing or cut off, do not attach it to the chart. Instead, add a tag to the case in Mosai and follow up with the Physician/NPP office.

   

4. If there is a marking or notation from the Physician/NPP’s office on the order, immediately escalate the order to the Clinical Supervisor and complete an ORDER FOLLOW UP NOTE documenting that escalation. Refer to process O-11-330 Orders Management- Order Escalation to Clinical Supervisor for entire detailed instructions on this step.

   • Examples of marking and/or notations:

     

     

     

5. If the order containing a marking or notation from the physician/NPP is not signed:
   • Do not further process the order.
   • Collaborate with the clinical supervisor to receive direction on appropriate next steps in obtaining a valid signed order; corrections to the order may be needed on the clinical side prior to following up to obtain signature and date.
6. If the order containing a marking/notation from the physician/NPP is signed, after completing step 4, continue with the following steps.
7. Confirm items completed in the initial review are complete:
   • Any marking/notations from the physician/NPP
   • Any missing pages/portions of pages cut off
   • Unacceptable fax quality (blurriness/illegibility)
8. Ensure the physician/NPP signature and date, whether handwritten or electronic, are acceptable. Requirements for provider signature and date are very specific.
   • Examples and resources on these requirements are found in O-11-321 Provider Signature Tip Sheet. Reference this process to ensure the signature/date meets the qualifying criteria.
   • NOTE: At least one page of the order number must contain an acceptable signature and date.  It is not required that all pages have a signature, but we must receive all pages of the order back from the provider. This rule is for compliance reasons and to ensure we are not missing a page that may have a notation.
   • If any of the criteria are not met, do not attach to chart. Retain the document in Mosai and follow up with the Physician/NPP to obtain an acceptable signed/dated order. Tags and/or follow-up notes should be added to the order within Mosai to assist with tracking.
   • For additional examples and resources tied to provider signatures and useful verbiage for following up with providers, refer to O-11-321 Provider Signature Tip Sheet.
9. If all previous criteria are met, then compare the Physician/NPP signature to the name listed on the order. If there is any discrepancy in the signature, credentials, or elsewhere notated on the order or cover page that indicates the signing provider is not the Physician/NPP listed, follow-up is needed as indicated in the following processes:
   • O-11-310 Orders Management- 485/POC Provider Follow-Up and Escalation
   • O-11-350 Orders Management- Update Provider on Signed 485/POC
   • O-11-380 Orders Management- Update Provider on Signed Physician Order
10. Once all the steps in this process and referenced processes (as applicable) are completed, the order may be attached to the medical record in HCHB.

📅 Effective: 04.29.2024 | 🛠️ Revised: 07.09.2026 |  ✅ Approved: JFJ