Wiki Vaccinations

[dawn1170]

I am auditing a chart and the physician does not mention on the medical record that pt is to receive a Flu vaccine however; they provided me with a vaccine administration form and the immunization records.

My question is: Does the physician need to document on the office visit note that pt is to receive the vaccine today????

 

[LOVE2CODE]

YES...If not documented, not done......

 

[heathergirl]

I agree- it has to be requested by the Dr. Any procedure, injection, or diagnostic test must be recorded by the Dr.

 

[dballard2004]

I totally agree. There must be documentation to support the vaccine. Otherwise, it can't be coded/billed. Thanks.

 

[dawn1170]

That is what I thought, thanks for confirming it.

Thanks

 

[dawn1170]

Ok I have one more question, I need to find reference material to provide to the MD. I have read somewhere that it must be ordered and I can't find it. Do you know where I can find "written documentation" to support this?

Thanks for all your help