Wiki Vaccine documentation

[cyn123170]

I need assistance with proper documentation of vaccines in the patient visit note. We have a new Pediatrician who prefers to only document a vaccine in the vaccine log tab of the EMR. Is this adequate when it come to proper documentation of vaccines to ensure that we do not fail a chart audit. I feel that all information regarding the vaccine administration should be documented in the visit note as well as the vaccine log. I am a CPC and was taught that if it is not documented in the note, it did not happen. In the note she states that vaccines were given but there is no location, route, time, or dosage documented in the note, it is only in the EMR vaccine tab. Is this adequate documentation or does the information regarding the vaccine administered have to be documented in the visit note as well as the vaccine log? Does the auditor only view the visit notes or the entire chart (including vaccine tabs) when performing an audit? If the information is not documented in the visit note how would anyone know that the vaccine was actually given?

Help me please!!


Thanks for your help
Cynthia Whitelow, CPC