Policy #: 3.4
Title: AUTOMATIC STOP DATES
I. PURPOSE: To establish a reasonable time to stop orders for drugs and biologicals not
specifically prescribed as to time or number of doses in accordance with CMS Conditions of
II. POLICY: For inpatient medication orders without a stop date or number of doses specified, the
medication orders will expire 365 days after their start date and time. The Pharmacy and
Therapeutics Committee and/or the Pharmacy Department may identify specific drugs requiring a
predetermined stop date shorter than 365 days.
A. Medication orders placed in the electronic medical record without a stop date or number of
doses specified will expire 365 days after the start date and time.
B. Print groups will be maintained in the electronic active orders reports to alert inpatient
nursing, pharmacist and physician staff about medications that are about to expire and
medications that have expired, and will appear as medications needing review.
1. If the expiration time is accurate, the provider is not required to take action.
2. To apply an immediate stop to the medication order, use the discontinue button to
update the medication stop date and time to the current date and time.
3. To modify/renew the order, use the modify button to open the order composer and
make the order changes required.
4. Once the expiration date and time have elapsed, expiring medications without a stop
date will continue to display under the currently active orders section to allow the
provider to take action on the order.
5. To reorder the medication, use the reorder button to open the order composer and
complete the order
6. The expiring medication orders report will be reviewed daily by pharmacists.
Pharmacists will contact prescribers for order clarification if a medication order has
been active for greater than 360 days.
C. The following medications will have a predetermined, prebuilt, stop date of less than 365
1. Ketorolac (5 days)
2. Total Parental Nutrition (1 day)
3. Intravenous acetaminophen (2 doses)
4. Restricted antimicrobials as defined in Pharmacy Policy 13.19 (96 hours)
Director of Pharmacy