Less Topics

Patient ID: Identifiers

Patient ID: Transfusions

Verbal Orders

Abbreviations

More Topics
The Joint Commission

NPSG.01.01.01

NPSG.01.03.01

PC.02.03.01, EP 20

IM.02.02.01, EPs 2 and 3

The Centers for Medicare & Medicaid Services (CMS)

CMS regulations include basic safety practices for medication administration, which must reflect accepted standards of practice, often referred to as the "five rights." Hospitals must ensure medication is administered to the right patient through acceptable patient identifiers that might include: the patient's full name; and identification number assigned by the hospital; or date of birth. These identifiers must be confirmed via the patient's wrist band, patient ID card, patient statement, or through other means outlined in the hospital's policy. For more information, refer to "Basic safe practices for medication administration," as well as Pharmaceutical Services CoP at §482.25 and Quality Assessment and Performance Improvement CoP at §482.21

According to CMS, blood transfusions and intravenous medications must be administered in accordance with state low and approved policies and procedures. Additionally, hospitals must adhere to medication administration regulations that require hospitals to ensure medication is administered to the right patient through acceptable patient identifiers that might include: the patient?s full name; and identification number assigned by the hospital; or date of birth. These identifiers must be confirmed via the patient?s wrist band, patient ID card, patient statement, or through other means outlined in the hospital?s policy. For more information, refer to §482.25(c)(4): http://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_a_hospitals.pdf

Under CMS regulations, verbal orders should be used infrequently and not become common practice since they can contribute to medical errors. Hospitals should develop policies that describe situations in which verbal orders may be used and mechanisms to establish the identity and authority of the practitioner issuing the order. The hospital should establish effective protocols for clear and effective communication and verification of verbal orders. CMS expects hospitals to use nationally accepted read-back verification practice to be implemented for every verbal order. For more information, refer to §482.23(c)(3)(i):

CMS requires hospitals to develop policies and procedures that minimize drug errors. Standardization of prescribing and communication practices to include the avoidance of dangerous abbreviations. For more information, refer to §482.25

Alabama

Alabama does not specifically address patient identification requirements

Alabama does not specifically address patient identification during blood transfusions; however, blood transfusions should be administered according to state law and approved medical staff policies and procedures.

Alabama allows verbal orders, but stipulate that they are to be used infrequently. When used, they should only be accepted by staff members that are authorized to do so by hospital policies and procedures consistent with federal and state law. Verbal orders should be dated, timed, and authenticated not more than 30 days following entry of any order by the ordering practitioner who is responsible for the care of the patient.

Alabama does not address the use of abbreviations, but does require medical record entries are legible, complete, dated, timed, and authenticated in written or electronic form.

Alaska

Alaska does not specifically address patient identification. However, under surgical service requirements, surgeons must confirm the patient's identity and the site and side of the body to be operated on

Alabama does not specifically address patient identification during blood transfusions; however, blood transfusions should be administered according to state law and approved medical staff policies and procedures.

Alabama allows verbal orders, but stipulate that they are to be used infrequently. When used, they should only be accepted by staff members that are authorized to do so by hospital policies and procedures consistent with federal and state law. Verbal orders should be dated, timed, and authenticated not more than 30 days following entry of any order by the ordering practitioner who is responsible for the care of the patient.

Alabama does not address the use of abbreviations, but does require medical record entries are legible, complete, dated, timed, and authenticated in written or electronic form.

Arizona

A patient must be identified to ensure the patient receives proper medical services. Arizona regulations require hospital administrators to ensure medical records include the patient's name, address, date of birth, name and contact information of the patient's representative, and any known allergy including medication allergies or sensitivities.

Arizona requires clinical laboratory services and pathology services to created policies and procedures for procuring, storing, transfusing, and disposing of blood and bodily fluids. Additionally, hospitals should have policy to investigate transfusion adverse reactions through the quality management program. For more information, see Title 9. Health Services, Chapter 10 Department of Health Services Health Care Institutions: Licensing. Article 2. Hospitals: R9-10-219. Clinical Laboratory Services and Pathology Services.

Arizona regulations require that verbal orders for medication services are taken by a nurse, unless otherwise provided by law. Additionally, verbal orders must be authenticated by the medical staff issuing the order. For more information, see Title 9. Health Services, Chapter 10 Department of Health Services Health Care Institutions: Licensing. Article 2. Hospitals: R9-10-421. Medication Services and R9-10-411. Medical Records.

No current regulation under this topic.

Arkansas

During the admission process, each patient admitted to the hospital will receive an identification bracelet.

Arkansas regulations require that blood transfusions must be administered in accordance with state law and approved medical staff policy, but do not mention patient identification for the use of blood transfusions specifically.

Telephone and verbal orders should be used infrequently.

Although there is no current regulation under this topic, abbreviations are not acceptable in surgery records.

California

California regulations require each patient to be provided with a wristband identification tag that includes the name of the patient, the admission number, and the name of the hospital.

California does not address patient ID for transfusions.

Verbal orders for drugs shall be recorded promptly and given only by authorized personnel and those authorized to prescribe them.

No current regulation under this topic.

Colorado

Colorado regulations do not specifically address patient identifiers; however, hospitals are required to keep a complete and accurate medical record on every patient that includes adequate identification.

During a blood transfusion, Colorado requires hospitals to accurately identify and verify the patient, the patient's blood specimen, type, crossmatch, and expiration date of donor blood.

Colorado regulations require that verbal orders should be authenticated by a physician or a responsible individual who has the authority to issue verbal orders within 48 hours after the time the order is made unless the read-back and verify process is used. The individual receiving a verbal order should record the date and time of the order and sign the order in accordance with hospital policies. A read-back and verify process requires the individual receiving the order to immediately read back the order to the physician who will immediately verify its accuracy. In this case, the verbal order can be authenticated within 30 days after the date of the patient's discharge.

Colorado does not currently have regulation under this topic.

Connecticut

Connecticut regulations require each facility to maintain a complete medical record for each patient that includes name, date of admission, recent dress, date of birth, sex, marital status, religion, referral source, Medicare/Medicaid numbers or other insurance numbers, and next of kin or guardian, and telephone number.

Connecticut does not publish regulations concerning patient identification for transfusions; however, the state does require facilities to maintain a complete medical record for each patient.

Connecticut regulations require orders that are given verbally or by telephone to be recorded by an on duty licensed nurse or healthcare practitioner with the statutory authority to accept orders and must be signed by the physician on the next visit.

Connecticut regulations require healthcare facilities to train employees on the administration of medications, which should include any commonly used abbreviations.

Delaware

Delaware requires hospitals to comply with The Joint Commission's Standards for Accreditation of Hospitals Plus Provisional Interpretations.

Delaware requires hospitals to comply with The Joint Commission's Standards for Accreditation of Hospitals Plus Provisional Interpretations.

Delaware requires hospitals to comply with The Joint Commission's Standards for Accreditation of Hospitals Plus Provisional Interpretations.

Delaware requires hospitals to comply with The Joint Commission's Standards for Accreditation of Hospitals Plus Provisional Interpretations.

Florida

Florida requires hospitals to maintain health records that include patient identification. Hospitals must also maintain a complete system for patient identification, including a system for all emergency room cases and disasters.

Florida does not have requirements for patient identification for transfusions.

Florida does not have specific requirements for verbal orders, but regulations do require each hospital to obtain, manage, and utilize information and transmit patient information in a timely and accurate manner.

Florida regulations state that symbols and abbreviations should only be used when they have been approved by clinical staff and must be accompanied by an explanatory notation. The final diagnosis must be recorded in full without the use of abbreviations.

Georgia

Georgia requires inpatient medical records to contain a unique identifying number and a patient identification form that includes name, address, date of birth, sex, and person to be notified in an emergency.

Georgia does not have specific requirements for patient identification for blood transfusion, but does address obtaining and documenting appropriate patient consent.

Georgia regulations dictate that hospitals should limit the use of verbal/telephone orders, which should only be used in situations where immediate written or electronic communication is not feasible, and the patient's condition requires immediate action. In those cases, verbal/telephone orders should immediately enter the order into the medical records, sign and date the order, with the time noted, and enter the dose administered. The individual receiving the order should immediately repeat the order and the prescribing physician should verity it is accurate. The individual receiving the order should document "repeated and verified." The order should be authenticated by the ordering physician according to medical staff policies, but the hospital should require authentication no later than 30 days. As an alternative, the hospital can require verbal/telephone orders be authenticated within 48 hours, except when the patient is discharged within 48 hours, in which case authentication should occur within 30 days of patient discharge.

Georgia regulations require that staff members in charge of maintaining medical records keep a list of accepted abbreviations, symbols, and terminology within the hospital to be used in entries on the medical record.

Hawaii

No current regulation under this topic.

Although there are no specific regulations concerning identification of the patient prior to a blood transfusion in Hawaii's rules, there are some general rules about blood transfusions, such as transfusions should only be done under the supervision of a pathologist or physician qualified in immunohematology and hemotherapy.

Within twenty-four hours of receiving any verbal or telephone orders for medication, they must be recorded and signed by the person receiving them and countersigned by the attending physician.

No current regulation under this topic.

Idaho

Idaho does not specifically address patient identifiers, but does note that patient identification must be included in the medical record. Under surgical services, policies and procedures must include verification of patient identity.

Idaho requires laboratories to develop procedures for patient and test identification for blood transfusions.

Idaho requires that verbal medical orders are given and accepted by persons authorized by Idaho law and hospital policies and procedures. Verbal and telephone orders must include the name of the person giving the order and the first initial and the last name and professional designation of the healthcare practitioners receiving the order. The order should be promptly signed and authenticated by the prescribing physician according to hospital policy. This regulation applies to both medical and drug orders.

Idaho has no current regulations for abbreviations.

Illinois

Identification must always be affixed to the patient, particularly children, who cannot identify themselves.

Illinois requires that a medical staff committee review all blood transfusions and make recommendations concerning the policies of such practices.

Verbal orders must be signed by the prescriber before he/she leaves the area. Telephone orders must be signed no more than 72 hours after the order was given and should be addressed in hospital policy.

There is no current regulation for Illinois under this topic.

Indiana

Hospitals must have written patient care policies and procedures that include a reliable method of patient identification, with particular attention given to identification of infants, young children, and others unable to identify themselves.

Indiana does not have specific requirement for patient identification for blood transfusions, however hospitals are required to administer blood transfusions and intravenous medications according to state law and approved medical staff policies and procedures.

Verbal or telephone orders should be accepted only by personnel that are authorized to do so by the medical staff rules. All verbal orders must be authenticated by the responsible individual in accordance with hospital policy within 48 hours, unless a read back and verify process is utilized. If the patient is discharged within 48 hours of the time the verbal order was given, the order should be authenticated within 30 days of discharge. When utilizing a read back process, the individual receiving the order must immediately read back the order to the ordering physician, who will immediately verify its accuracy. The receiving individual shall document the read back and verification in the patient's medical record and must be authenticated within 30 days of patient discharge.

There is no current regulation under this topic.

Iowa

Iowa does not have requirements for patient identification.

Iowa does not have requirements for patient identification.

All verbal orders must be authenticated in writing and signed by the prescribing practitioner within a 30 day following a patient's discharge. Telephone, oral, or electronic medication orders can only be accepted by personnel that are authorized to do so by hospital policies according to federal and state law.

Iowa does not have requirements for abbreviations.

Kansas

Kansas does not specifically address this topic, but does address patient identification of newborns and mothers in the maternity ward.

Patient identification during blood transfusions is not addressed by Kansas regulations.

According to Kansas regulation, verbal orders must be signed and dated by the receiver as soon as possible. The person entering the orders must sign and date the order as soon as possible, and the order must be authenticated within 72 hours or 30 days of a patient's discharge, whichever comes first. The person receiving a verbal order for medication, a diagnostic test or treatment must immediately transcribe the order, repeat the order to the person issuing it, an annotate the order on the patient's medical record as repeated and verified.

This topic is not currently addressed under Kansas regulations.

Kentucky

Hospitals must have a system for identifying each patient from time of admission to time of discharge that includes the name of the patient, hospital ID number, date of admission, and the name of the attending physicians.

Kentucky doesn't have specific requirements regarding patient ID for transfusion, but state regulations do requires an effective procedure for recording accidents involving transfusion reactions, and a medical staff committee should review transfusions and make recommendations for governing policies.

Circumstances that require a verbal order should only be given to a licensed practical or registered nurse, paramedic, or pharmacist and shall be signed by a member of the medical staff or other ordering practitioner. A verbal order for a diagnostic test may be given to a licensed practitioner acting within his statutory scope of practice and the hospital's protocols. The person receiving a verbal order for medication, a diagnostic test or treatment must immediately transcribe the order, repeat the order to the person issuing it, an annotate the order on the patient?s medical record as repeated and verified.

This topic is not currently addressed by Kentucky regulations.

Louisiana

This topic is not addressed under Louisiana's hospital regulations.

This topic is not addressed under Louisiana's hospital regulations.

Under Subchapter B §9321(A)(5) of the Louisiana Hospital Licensing Standards, medical staff bylaws must include "specifications for orders for the care of treatment of patients, which are given to the hospital verbally or transmitted to the hospital electronically, whether by telephone, facsimile transmission or otherwise." Medical staff members have up to 10 from the time the order is transmitted to provide a signature or countersignature.

Abbreviations are not addressed in Louisiana regulations.

Maine

Maine does not have specific regulations pertaining to patient identification; however, under Section 3.1 of the state hospital licensing standards, hospitals must meet the Medicare Conditions of Participation along with any federal standards or regulations.

Maine does not have specific regulations pertaining to patient identification during transfusions; however, under Section 3.1 of the state hospital licensing standards, hospitals must meet the Medicare Conditions of Participation along with any federal standards or regulations. Section 3.4 adds that CMS requirements are applicable to all patients, regardless of the insurance provider.

Maine does not have specific regulations pertaining to verbal orders; however, under Section 3.1 of the state hospital licensing standards, hospitals must meet the Medicare Conditions of Participation along with any federal standards or regulations. Section 3.4 adds that CMS requirements are applicable to all patients, regardless of the insurance provider.

Maine does not have specific regulations pertaining to abbreviations; however, under Section 3.1 of the state hospital licensing standards, hospitals must meet the Medicare Conditions of Participation along with any federal standards or regulations. Section 3.4 adds that CMS requirements are applicable to all patients, regardless of the insurance provider.

Maryland

Service standards for hospitals in Maryland include most Joint Commission standards.

Maryland regulations do not currently address this topic.

Service standards for hospitals in Maryland include most Joint Commission standards.

Service standards for hospitals in Maryland include most Joint Commission standards.

Massachusetts

Massachusetts does not have specific regulations pertaining to patient identification; however, under 130.200 hospitals must meet the Medicare Conditions of participation along with any Joint Commission requirements if the hospital is accredited.

Massachusetts does not have specific regulations pertaining to patient identification; however, under 130.200 hospitals must meet the Medicare Conditions of participation along with any Joint Commission requirements if the hospital is accredited.

Massachusetts does not have specific regulations pertaining to patient identification; however, under 130.200 hospitals must meet the Medicare Conditions of participation along with any Joint Commission requirements if the hospital is accredited.

Massachusetts does not have specific requirements regarding abbreviations; however, under 130.200, hospitals must meet the Medicare Conditions of Participation along with any Joint Commission requirements if the hospital is accredited.

Michigan

Michigan does not have specific requirements for patient identification, but requires hospitals to keep accurate and complete medical records on all patients admitted.

Michigan does not have specific requirements for patient identification, but requires hospitals to keep accurate and complete medical records on all patients admitted.

Michigan state law indicates that verbal orders should be written into the records as such, and should be received only by a person or persons authorized by the administrator and the medical staff. The orders should be indicated as verbal orders, initialed by the physician's initials per the receiver's initials and countersigned by the physician at the time of the next visit.

There is no current regulation on this topic.

Minnesota

According to 4640.1000, Subpart 3: Information to be included: Medical records should be maintained from the time of admission to discharge and should include adequate identification data.

There is no current regulation for Minnesota.

Minnesota does not regulate verbal orders in general medical units; however, the state does have regulations under "Mental Health and Psychiatric Hospitals" that require emergency orders for seclusion or restraints given by telephone should be reduced to writing immediately and signed by a staff member within 24 hours.

There is no current regulation on this topic for Minnesota.

Mississippi

Although Mississippi does not have any regulations specifying two methods of patient identification, it does say that within a patient's medical record should be patient identification.

Although Mississippi does not have any regulations that specifically call for active patient identification prior to a blood transfusion, the state’s regulations do have rules about blood and blood products.

Although Mississippi does not have any regulations that discuss the protocol for receiving verbal orders, there is a time specification required by regulations.

There is currently no regulations concerning a necessary list of abbreviations, dose designations, acronyms, or symbols kept in each hospital for Mississippi. To find the state's general health facilities regulations, click the link below.

Missouri

Missouri does not have any specific regulations regarding this topic.

Missouri regulations require hospitals to provide patient identification through two unique identifiers during the safe-keeping and safe administration of blood and blood products.

According to Missouri hospital regulations, all verbal orders must be dated, timed, and authenticated according to hospital policy, but no later than 30 days. The order should be authenticated by the ordering practitioner or another practitioner responsible for the care of the patient, and should be kept in the patient's medical record. Authentication should include a written signature, initials, or computer-generated signature codes.

Missouri's regulations require used abbreviations to be approved, as well as there to be a list of handwritten abbreviations that should not be used.

Montana

Although Montana's regulations do not have language concerning the use of two patient identifiers, regulations do state that a core medical record should contain a form of patient identification, specifically his or her name, maiden name if relevant, address, date of birth, sex, and, if available, Social Security number.

Montana does not have any current regulation regarding identification errors with transfusions.

Montana does not have any current regulations concerning verbal orders.

Montana does not have any current regulations that concern creating a standardized list of abbreviations, symbols, acronyms, or dose designations.

Nebraska

Nebraska's regulations state that a patient's medical record and medication record must contain a method of identification for that patient.

Nebraska does not have any specific requirements for eliminating errors with blood transfusions by correctly identifying patients.

Verbal and telephone orders must be accepted, checked, and transcribed by a qualified staff member.

Nebraska does not currently have any regulations that require a list of standardized abbreviations to be used throughout a hospital.

Nevada

If passed, Assembly Bill 280 would require all Nevada hospitals to create safety checklists reminding healthcare workers how to identify a patient appropriately and make certain that the patient is provided with the specific treatment ordered by a healthcare professional.

According to Nevada regulation, blood transfusions must follow the policies and procedures developed by the hospital, with input from the medical staff.

According to NAC?449.343 Orders for medication and biological, when a telephone or verbal order is used to order medications or biologicals, the order must be accepted only by a person who is authorized by the policies and procedures of the medical staff, which must be consistent with state law, to accept such an order and signed or initialed by the prescribing practitioner in accordance with hospital policy.

 

New Hampshire

New Hampshire regulations do not specifically address patient identifiers, but medical records should be maintained and kept active for each patient admitted.

New Hampshire regulations do not address patient identification for transfusions.

New Hampshire regulations do not address verbal orders.

New Hampshire regulations do not contain any specific language that addresses abbreviations, acronyms, symbols, or dose designations not to be used in a facility.

New Jersey

Hospitals need to have a patient identification system that identifies all patients from the time of admission until the patient's release from the hospital.

New Jersey does not have a current regulation under this topic.

Medical staff policies should say who can give and receive verbal orders, as well as the time period in which they need to be verified.

New Jersey does not have a regulation regarding abbreviations, acronyms, symbols, or dose designations that should not be used.

New Mexico

According to 7.7.2.19 Policies, D. Identification, the hospital shall develop a method to identify employees, patients, personnel records and patient files.

New Mexico currently does not have a regulation under this topic.

Under 7.7.2.30 Medical Record Services, all orders shall be recorded and authenticated. All verbal and telephone orders shall be authenticated by the prescribing practitioner, or a practitioner authorized to sign on behalf of the prescribing physician, in writing within 72 hours.

Under 7.7.2.30 Medical Record Services, I. Authentication of Entries, symbols and abbreviations may be used in medical records if approved by a written facility policy, which defines the symbols and abbreviations and controls their use. There shall be only one meaning per symbol.

New York

Patient ID not specifically addressed.

New York regulations require that healthcare workers positively identify the recipient of a blood transfusion as well as the blood product prior to transfusion or infusion. Positive identification includes the patient's name and a unique numerical or alphanumerical identifier. When administrating a blood component, an additional physician, physician's assistant, registered nurse, licensed practical nurse, or board-certified cardiovascular perfusionist should also identify the recipient and blood component, unless another procedure to ensure accurate identification is used.

Verbal orders must be addressed in policies. The hospital must implement procedures regarding use and authentication of telephone orders. They must be in accordance with federal law and be authenticated by the prescribing practitioner as soon as possible. Verbal orders must be authenticated within 48 hours.

Abbreviations are not specifically addressed by New York hospital regulations.

North Carolina

Facilities shall maintain complete and permanent record of all patients including date, time, admission, discharge, address, date of birth, nearest of kin, provisional diagnosis, referring physicians, attending physician, identification bracelet or band.

North Carolina does not specifically address patient identification; however, under 10 NCAC 13B.4906, facilities that "provide for procurement, storage, and transfusion of blood" need to adhere to the American Association of Blood Banks (AABB) Standards of Blood Banks and Transfusion Services.

Verbal orders shall be countersigned by a physician within five days of issuance.

North Carolina regulations state that symbols and abbreviations are used in patient medical records should only be used when they have been approved by the medical staff and when there is a legend to explain them.

North Dakota

North Dakota doesn't specifically require hospitals to use at least two patient identifiers when providing care, treatment, or services. But it does require that patient identification and history of disease or injury will be kept in medical records.

North Dakota does not specifically address the topic of eliminating transfusion errors related to patient misidentification, but it does require that written policies and procedures for transfusion services be established and revised as needed.

Telephone and verbal orders may be used provided they are given only to qualified licensed personnel and put in writing, signed, or initialed by a healthcare practitioner responsible for the care of the patient.

No current regulation under this topic.

Ohio

Ohio does not specifically address patient identification, but it requires hospitals to have a quality improvement program.

Ohio doesn’t address the elimination of transfusion errors related to the misidentification of patients.

Ohio doesn’t address improving caregiver communication of verbal or telephone orders.

Ohio doesn’t address the standardization of abbreviations, acronyms, symbols, and dose designations.

Oklahoma

Adequate medical records shall be kept on every patient. Each record will include patient identification through various means.

Oklahoma does not specifically address patient identification for blood transfusions; however, hospitals should administer blood transfusions as required by written hospital policy in accordance with state and federal laws. The hospital should also establish a procedure for reporting adverse events and reactions with blood transfusions.

All verbal orders must be documented and signed by the prescribing physician within 48 hours, and only by an authorized physician or practitioner.

Oklahoma does not have a current regulation under this topic.

Oregon

Systems for patient identification shall include name, date, and signature.

Oregon doesn't specify how transfusion errors should be eliminated, but it does require that there is an effective, written quality assurance program to evaluate and monitor blood transfusions.

Oregon hospitals are required to have by-laws, medical staff policies, and medical staff rules and regulations regarding the acceptance of verbal orders, according to 333-505-0020. Furthermore, 333-505-0050 requires clinicians to document verbal orders with the name an title of the healthcare practitioner that gave the order, as well as the date and time, and authentication by the authorized individual that accepted the order. Verbal orders, including telephone orders, should be authenticated promptly by the order practitioner or another practitioner that is responsible for the care of the patient.

Only abbreviations approved by the medical staff may be used in medical records. All diagnoses and operations should be expressed in standard terminology.

Pennsylvania

Pennsylvania doesn't require the use of two patient identifiers when providing care, treatment, and services, but it does require each patient at admission to wear a form of visible patient identification such as an identification bracelet.

Pennsylvania does not specifically require hospitals to eliminate transfusion errors related to patient misidentification, but it does require that hospitals have the capability of providing transfusions to meet the needs of patients.

Verbal orders must be signed and authenticated within 24 hours.

Abbreviations and symbols may only be used if they are part of a list approved by the medical staff and a legend exists to explain them.

Rhode Island

For each patient seeking emergency care, a medical record shall be maintained.

Rhode Island has no current regulation under this topic.

All telephone or verbal orders must be put in writing by the person who took the order with his or her signature and date. Identification of the practitioner who gave the order must be recorded with his or her signature no later than the end of the next calendar day.

Rhode Island has no current regulation under this topic.

South Carolina

South Carolina regulations requires an admission report to be prepared for each patient with the following information: name, address, occupation, age, date of birth, sex, marital status, religion, county of birth, father's name, mother's maiden name, husband or wife's name, dates of military service, health insurance number, provisional diagnosis, case number, days of care, social security number, name of person providing information, emergency contact information, referring physician, contact information for attending physician, and that date and hour of admission.

South Carolina regulations require that hospitals that provide procurement, storage and transfusion of blood shall have acceptable facility and adhere to Standards of the American Association of Blood Banks outlined in the Standards for a Blood Transfusion Service. Records should also be kept on file indicating the receipt and disposition of all blood handled.

All medical records should contain consent forms for treatments and orders for medication and treatment signed by the prescriber or his designee. All verbal orders should be signed and authenticated by the prescriber within 30 days.

There is no current regulation under this topic for South Carolina.

South Dakota

South Dakota identifies twelve pieces of patient information that have to be contained within the patient's record and must show the condition of the patient or resident upon admission and through discharge.

South Dakota has a general policy on blood transfusions, but does not address the prevention of patient misidentification errors. See section 44:04:10:04.

All medical orders must be in writing and signed by the physician or the physician extender. Orders via telephone may be taken only when there is an urgent need to create or modify a medical order. The physician signs or initials the orders for nursing facility residents on the next visit to the facility. The physician should sign or initial any orders for hospital patients as soon as possible. Each patient’s or resident’s physician is responsible for documenting written orders and progress notes on the clinical record.

Those medications administered to the patient must be recorded in his or her medical record. Use of abbreviations and chemical symbols may be allowed but only if the hospital has a standard list of abbreviations and symbols approved for use by the medical staff. This list must be made available to members of both the medical and nursing staffs. Only licensed nurses, or those acting under the delegation of a licensed nurse, may administer medications.

Tennessee

Tennessee's regulations do not specifically address patient identification at admission.

According to 1200-8-1-.06, blood transfusions and intravenous medications must be administered in accordance with state law and approved medical staff policies and procedures. There must be a hospital procedure for reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs. No mention of patient identification protocol during transfusion is mentioned.

Verbal orders can only be accepted by those authorized to do so. Orders must be signed and initialed by the prescribing practitioner.

Tennessee regulations do not address this topic specifically.

Texas

Texas does not have specific regulations on patient identifiers.

According to §133.41. Hospital Functions and Services (o) Nursing Services, Transfusions shall be prescribed in accordance with hospital policy and administered in accordance with a written protocol for the administration of blood and blood components and the use of infusion devices and ancillary equipment. A specific process for identifying correct patients in this process is not specifically prescribed in the regulation, however. According to §133.48. Patient Safety Program, the hospital must report to the state health department a hemolytic transfusion reaction in a patient resulting from the administration of blood or blood products with major blood group incompatibilities

According to §133.41. Hospital Functions and Services (j) Medical Record Services, all verbal orders must be dated, timed, and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges which are consistent with the written orders.

While Texas regulations do not specifically address the use of abbreviations, they do address the clarity of medical records, stating that medical records must be consistent with hospital policies and procedures.

Utah

Although this topic is not specifically addressed by Utah’s hospital regulations, they do state that each patient’s medical record shall contain patient identification and demographic information that at least includes the patient’s name, address, date of birth, sex, and emergency contact information.specifically addressed by Utah’s hospital regulations.

Utah regulations do not specifically address patient identification, however hospitals that provide blood services must collect, store, and handle blood and blood components in such a way that they retain potency and safety. Additionally, blood and blood components must be properly processed, tested, and labeled.

According to Utah regulations, verbal orders must be accepted and transcribed by qualified personnel and authenticated within 30 days of the patient's discharge.

Utah regulations do not specifically address patient identification, however hospitals that provide blood services must collect, store, and handle blood and blood components in such a way that they retain potency and safety. Additionally, blood and blood components must be properly processed, tested, and labeled.

Vermont

State licensing requirements stipulate that hospitals keep complete and accurate records on each patient from admission to discharge which should include identification data.

Hospital regulations do not specifically address patient identifications for transfusions, but do require hospitals to keep complete and accurate medical records.

Under 18 V.S.A. Chapter 43A, the Patient Safety Surveillance and Improvement System, Vermont hospitals are required to report all events labeled as "serious reportable events" and specifications published and periodically amended by the National Quality Forum, including patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration).

Under 18 V.S.A. Chapter 43A, the Patient Safety Surveillance and Improvement System, Vermont hospitals are required to report all events labeled as "serious reportable events" and specifications published and periodically amended by the National Quality Forum, including patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration).

Virginia

Virginia regulations require hospitals to have a patient identification system for all patients, including newborn infants.

Virginia regulations require hospitals to have written policies and procedures for all phases of blood transfusion and storage. They do not specifically address patient identification in conjunction with blood transfusions, however hospitals are required to meet CMS laboratory regulations under 42 CFR Part 493, 42 CFR 482.27 and 21 CFR Part 606. Additionally, Virginia law requires each hospital needs to provide appropriate facilities and equipment for storage and administration of blood and blood products.

Virginia regulations require that verbal and telephone orders be used in the case of emergency. These orders must be signed no later than 72 hours after the order is given.

Virginia's hospital regulations do not currently address this topic.

Washington

Under Washington's patient care regulations, located in the administrative code's hospital licensing section, hospitals are required to have a reliable method for identifying each patient.

Washington state regulations do not specifically address patient identification during blood transfusions, but does require hospital policy to ensure proper preparation and administration of blood and blood products.

Washington hospital regulations included in the administrative code under the "management of information" section do not address having a specific process for handling verbal orders, but do require that they are recorded in the patient's medical record after being transcribed by qualified personnel.

Washington does not currently have any regulation under this topic.

West Virginia

West Virginia regulations require hospital medical records to include some form of patient identification.

West Virginia doesn't specifically address patient identification related to transfusion, but it under 7.2.j.2, hospitals are required to include some form of patient identification in hospital medical records. Additionally, under 10.3 Blood and Blood Products, hospitals must have a process for procurement, safekeeping and transfusion of blood products.

West Virginia Hospital Licensure says that only authorized persons can give or receive verbal orders. Verbal orders must also be countersigned by a physician.

West Virginia's Hospital Licensure says only abbreviations approved by medical staff members can be used in patients' medical records.

Wisconsin

Regulations require that the medical record staff ensure each patient's medical record contain accurate patient identification data.

Wisconsin does not specifically call for identification of a patient prior to a blood transfusion. The state does have some rules surrounding blood transfusions and the processes and procedures regarding them.

Wisconsin regulations state that all verbal and telephone orders be authenticated by a member of the medical staff that can prescribe within 24 hours of the order being placed.

According to Wisconsin regulations, symbols and abbreviations may be used in medical records if the definitions and use are approved and controlled by a written facillity policy. They do not have any language about which specific abbreviations and symbols can or cannot be used, just that hospitals should have their own definitions.

Wyoming

Under "Emergency Services," Wyoming requires hospitals to keep adequate medical records on every patient that includes patient identification of some kind. Additionally, under Health Information and Management Systems, Wyoming requires hospitals to maintain medical records with sufficient information to justify and warrant the treatment and end results, and must include patient idenfication.

This topic is not addressed specifically. Wyoming regulations require that blood transfusions are performed by specially licensed individuals, but they do not specify patient identification requirements for the process.

Only registered nurses are to be given telephone orders and within 48 hours the order must be signed and initialed by the physician. Telephone orders should be used sparingly.

Wyoming health regulations do not address abbreviations.

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