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vaccinations

  1. #1
    Default vaccinations
    Medical Coding Books
    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????

  2. #2
    Smile
    YES....Have you heard the phrase "NOT DOCUMENTED, NOT DONE".....

  3. #3
    Default vaccinations
    Yes, I have heard that saying and have seen it in writing but now that I need to reference it I can't find it. Do you know where I can find "written documentation" to support this?

    Thanks

  4. Default
    I Would Say It Does Not Have To Necessarily Be Documented In The Patients Note For That Day But Having It Noted Under Immunizations Or Having A Consent Form That Is In The Medical Record Would Be Good Enough. The Md Does Not Have To Spell It Out In The Chart. For Example In My Office We Have A Walk In Flu Clinic So Individuals Come In As They Please And The Nurse Gives The Vaccine. She Documents It In Their Immunization File And Files The Consent Form Away. Hope This Helps. Thanks Nicole Wessell, Cpc

  5. #5
    Location
    Cactus Wren
    Posts
    14
    Thumbs up Vaccinations
    I agree with JWESS. As long as there is documentation of the flu vaccine being given, I would give credit and code for it.

  6. #6
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    I also agree that credit should be given for the vaccination...as long as there is a vaccination record and notation of the date given. It also helps if the nurse giving the vaccination notes the location given and lot # of the vaccine.

  7. #7
    Default
    Quote Originally Posted by JWESS View Post
    I Would Say It Does Not Have To Necessarily Be Documented In The Patients Note For That Day But Having It Noted Under Immunizations Or Having A Consent Form That Is In The Medical Record Would Be Good Enough. The Md Does Not Have To Spell It Out In The Chart. For Example In My Office We Have A Walk In Flu Clinic So Individuals Come In As They Please And The Nurse Gives The Vaccine. She Documents It In Their Immunization File And Files The Consent Form Away. Hope This Helps. Thanks Nicole Wessell, Cpc
    My thoughts exactly....

    Have a good day,
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

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