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Wiki Nursing Documentation

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jboes41527

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I'm wondering if anyone can share how their facility has the nurses documenting the injections and infusions that are given to patients, whether they are inpatient or observation?? I'm having some issues with the documentation being on the MAR in our medical record, and often missing key information as site of injection of start and stop times. I'm looking for a way to accurately get this information captured, that's not going to burden the nurses, but allow our coders to accurately capture charges for those services on our outpatients. Thoughts or ideas?
 
Jessica,

Besides checking the MAR, check the nursing notes in the patient's medical record for documentation regarding medication, IV administration, routes, times, etc.

Kim
 
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