mrdave
Guest
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, the his is sufficient because they wouldn't do anything else other than give the full syringe o fmedication. 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 bes t 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.
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 bes t 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.