Verbal Medication Order Read-Back and Documentation
Key Points
- Verbal orders are high-risk communication events and should be used only when needed.
- Immediate read-back is required to verify accuracy of the received order.
- The order must be documented right away in the chart with complete components.
- Provider review/signature and policy compliance are required to finalize the order safely.
Equipment
- EHR order-entry and charting access
- Medication order component checklist per facility policy
- Provider-notification and co-sign tracking workflow
Procedure Steps
- Confirm the verbal order is clinically necessary and permitted by current policy.
- Capture the full order details as spoken, including medication name, dose, route, timing/frequency, and indication when applicable.
- Read the complete order back to the provider verbatim to verify message accuracy.
- Clarify any ambiguity immediately before proceeding.
- Enter the verified verbal order into the patient chart without delay.
- Mark/order-status according to local policy for verbal-order authentication.
- Initiate provider review/signature follow-through within required timeframe.
- Re-check allergy status and interaction risks before first administration.
- Escalate unresolved discrepancies or missing authentication per safety policy.
Common Errors
- No read-back performed → wrong drug/dose/route risk.
- Delayed chart entry → transcription loss and continuity gaps.
- Missing provider co-sign follow-up → compliance and legal risk.
- Proceeding with unclear order language → preventable medication error.
Related
- medication-administration-safety-measures - Broader safety framework for order verification and administration.
- medication-rights-and-three-checkpoint-verification - Bedside rights checks after order finalization.
- medication-error-reporting-and-escalation - Response pathway when order communication errors are identified.