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Question on documentation of meds given

  1. Default Question on documentation of meds given
    Medical Coding Books
    Auditing E/M's for a physician. In his clinic dictation patient comes in with a sinus infection.
    The physician states he puts the patient on an antibiotic but does not state the name of the antibiotic, dosage or directions. I realize that it should be documented, because it is part of good patient care. However, before I confront the physiican are there any regulations to the effect that state the name etc must be documented. This has happened several times lately. Would like to have my ducks in a row before approaching the physician. Can be kind of prickly sometimes. Any advice would be helpful. Thanks

  2. #2
    Is there another spot in the patient chart where the medication is documented? Sometimes our docs feel that if it's documented in the chart, it's redundant to put it in the dictation as well. I would just stress that it's important for the patient's medical record that the information is as complete as possible.

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