Nursing Documentation

PennyG

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Patient in for a preventative exam with immunizations. The physician has documented all elements including the diagnosis. The nurse then documents the immunizations in the Assessment and Plan. Her name is listed on the immunizations. The physician signs off on the note after the nurse documents the immunizations. Are the immunizations billable with the nurses name listed in the A&P rather than the physician?

Or, how about, can the nurse document in the assessment and plan? Would that be acceptable when determining the level of service?
 
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