F0842

E

Improper Documentation of Ordering Physician for Telephone and Medical Orders

Los Angeles, California Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

Facility staff entered telephone and other medical orders under the attending physician’s name rather than under the actual prescriber’s name, contrary to accepted standards and the facility’s own policy. During interview, one physician (MD1) reported that when telephone orders were given by members of her medical team (MDs, NPs), facility staff would document the orders using her name as the ordering physician. MD1 stated she had been informed that the facility’s electronic medical record system did not include the names of the other medical team members as options for the ordering provider. Another physician (MD2) confirmed that the computer program used for order entry only allowed selection of the attending physician’s name and did not allow the ordering MD to enter orders under their own name, making it difficult to identify which covering MD actually gave the order. Review of the facility’s Pharmaceutical Services Policy and Procedure Manual, dated 1/2025, showed that medication telephone orders were required to be countersigned by the prescriber.

This practice resulted in difficulty identifying the ordering physician’s name in the medical record and had the potential to mislead the healthcare system and create potential for fraud, as documented by the surveyors.