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EMR and flu shots

  1. #1
    Location
    Greeley, Colorado
    Posts
    2,045
    Question EMR and flu shots
    Medical Coding Books
    I'm wondering if anyone else is having this issue, or if it is even an issue. If patients come in for flu shot clinics, the immunization itself is not being abstracted into the immunization record in EMR; it is simply scanned in to another location within that EMR but it's hard to find. Likewise H1N1. Is it ok to just scan this info in and not apply it to the patient's immunization record? If there was an outside audit for these immunizations, it could be very tricky for the auditor to find the documentation. I need some opinions and help please.
    Lisa Bledsoe, CPC, CPMA

  2. #2
    Location
    Greeley, Colorado
    Posts
    2,045
    Exclamation Please help!
    I really need some advice/opinions/guidance on this. I'm being challenged by my EMR dept and administration.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Location
    Phoenix, AZ
    Posts
    620
    Default
    Hi Lisa,

    We sometimes had this situation at a previous employer. If the documentation is available, tricky or not, it is in the patient's chart. As coders we really wanted the information in the visit note, however it didn't always make it to there.
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Thanks Cyndi...I agree, as a coder I want it where it can be easily located. I don't want to have to search for it and I don't believe an outside auditor will either (auditors are usually coders first...). Guess I'll let this one slide and hope if it comes up in an outside audit that I will be allowed to help locate it.
    Lisa Bledsoe, CPC, CPMA

  5. Default EMR & Flu Shots
    Hi Lisa,
    In some departments that i have worked at in the past, scanned documents will be posted in a section (of each patient's chart using EPIC) called media and in most cases providers wont consider going into that section just to see the scanned documents and chances are that the immunization info will be ignored. Each department with the right log in profile has the means to input the immunization data into the immunizations section (In EPIC). If you facility does EHR training for the departments then I would encourage them to create a work flow and train the departments to input and update the immunization records so that everything is in the right area so when you are audited you will be prepared to provide the necessary information without delay this will also be beneficial for when the patient needs a immunization record for school or work and if there is a recall of the product companies can easily identify who has taken it and address the issue with accuracy.
    -Jeff

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