lillianivy
Networker
I need help.
2 or more drugs given in same bag or separate bag. In our EMR for the MAR where the drugs are documented it has start and stop times, dose amount, waste, unit, route, fluid, volume. When 2 or more drugs are given simultaneously they will have the same start and stop times. The nurses do not document rather they were given in the same bag or separate bag. They claim I am to figure it out by the fluid and volume documented. My dilemma is that there are occasions where the fluid and volume where the same when 2 or more drugs were given concurrently in separate bags. So it looks like they were given in same bag per documentation, but actually give in separate bags. We have come across this issue when we have had a claim audited. Since this can occur I have suggested the nurses take the extra step to document if the drugs are in separate or same bags. Well, I have received some backlash. As a coder I want to follow all rules and have clear documentation. I understand the nurses feel that documenting the fluid and volume is sufficient enough. So my question is.... Is that sufficient documentation, the fluid and volume, or does it need to clearly state same or separate bags?
Thank you,
Lydia
2 or more drugs given in same bag or separate bag. In our EMR for the MAR where the drugs are documented it has start and stop times, dose amount, waste, unit, route, fluid, volume. When 2 or more drugs are given simultaneously they will have the same start and stop times. The nurses do not document rather they were given in the same bag or separate bag. They claim I am to figure it out by the fluid and volume documented. My dilemma is that there are occasions where the fluid and volume where the same when 2 or more drugs were given concurrently in separate bags. So it looks like they were given in same bag per documentation, but actually give in separate bags. We have come across this issue when we have had a claim audited. Since this can occur I have suggested the nurses take the extra step to document if the drugs are in separate or same bags. Well, I have received some backlash. As a coder I want to follow all rules and have clear documentation. I understand the nurses feel that documenting the fluid and volume is sufficient enough. So my question is.... Is that sufficient documentation, the fluid and volume, or does it need to clearly state same or separate bags?
Thank you,
Lydia