DEPARTMENT: Laboratory
POLICY DESCRIPTION: Laboratory Standing Orders
APPROVED: February 22, 2000
EFFECTIVE DATE: February 22, 2000
REFERENCE NUMBER: LAB .008

SCOPE:
All Hospital Departments.

PURPOSE:
To ensure laboratory standing orders are used in accordance with CMS guidelines.

POLICY:
Laboratory standing orders are valid when documented in the patient's medical record as medically necessary, and monitored by the ordering physician.

DEFINITIONS:
Laboratory standing orders: tests ordered as part of an extended course of the patient's treatment for outpatients who require monitoring over a period of time.

PROCEDURE:
All laboratory orders must comply with Medicare, Medicaid, and other Federally funded payor guidelines.

1. Laboratory standing orders must be in written form, authenticated, and include a duration, frequency, diagnosis, physician signature, and be no more than 12 months old. Laboratory personnel must review standing order documentation at the time of service. If the standing order lacks any of the required elements, personnel must contact the ordering physician or health care provider to obtain applicable written or faxed information. Refer to Attachment A.

2. Laboratory personnel must document active and expired standing orders. Attachment A is the standard format unless a special format has been approved in advance.

3. Expired standing orders must be brought to the attention of the ordering physician by the laboratory staff and a new order or cancellation must be obtained (see Attachment B for standard Physician memo). Expired Standing Orders that are not renewed or confirmed within 30 days of physician notification must be removed from the active file but retained in an expired standing orders file.

REFERENCES:
The Office of Inspector General's Compliance Program Guidance for Clinical Laboratories, August 1998.

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