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Old 08-08-2012, 07:52 PM
mrdave mrdave is offline
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Default Medication administration - dosage documentation

Having conflict with clinics. They feel if they have recorded the concentration of the drug, site injected, expiration date, who gave the drug, etc. without including the specific statement of dosage, that this is sufficient because they wouldn't do anything else other than give the full syringe of medication. This is followed by, "if we gave something different, we would have documented it that way."
I am from the other camp, I feel they need to state specifics, I gave 40 mg of Depo-Medrol," or even better, "Depo-Medrol 40mg/ml, administered 1ml."
Having a rough time documenting this basic need for documentation in CPT guidelines, or HCPCS. The best source so far is nursing books listing the 6 r's: Right Documentation, Right Medication, Right Dosage, Right route, Right Time, with the Right Documentation.
Anyone with specific references or input appreciated.

Last edited by mrdave; 08-08-2012 at 07:54 PM.
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Old 08-09-2012, 12:10 AM
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Default agree

This is a universal to document dosage for safe clinical practice and help in assinging correct HCPCS codes.

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