Yes, it should always be documented. If it is not documented it is not done, nor billable. You have no proof that it was done in your office. The patient could have went to an outside lab and had it drawn. Also, from a patient care and liability standpoint it is necessary to document any procedure especially an invasive one. The patient may have a complication related to the procedure, or a question about the procedure that if not documented you cannot appropriately address. I have noticed a lot of offices failing to document venipuncture and injections, and as a nurse I would never leave myself open to that liability.
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