All verbal orders must be authenticated within 48 hours. This means signing, dating, and timing by the practitioner or covering provider. Waiting until the record shows on-line is not sufficient as 48 hours have often elapsed before that.
When documenting a diagnosis please be consistent in documenting the treatment, monitoring, and the significance of this diagnosis to the treatment of the patient.
It is not necessary to dictate patient medications in the discharge summary. A copy of the discharge medication reconciliation now accompanies the discharge summary.