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Wiki Respiratory Documentation

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pammalou

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Monticello, MN
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I have a dilema that I am in currently. Our EMR documents in the Med Rec portion of the patients chart anytime a med is pulled from the pixus for a patient. It time and date stamps the medication. I have a question from nurses as to why I continually am asking them for documentation of time given to the patient for nebulizers, MDI, etc and they say that they should not have to document seperate as the medication pulling charges should state that it was given. I disagree, is there anywhere that I can go to for written proof or am I totally incorrect in my line of thinking?? Any help would be greatly appreciated as this is a huge issue for me right now.

Thank you,:confused:
 
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