I have discovered that the Nurse/Med Tech are NOT documenting when they give a Vaccine or injection. The Physician is dictating that the vac./inj was given; but does not mention that the Nurse/Med Tech gave the inj etc.
" Pneumovac was given" is the documentation. ???????
Am I crazy to be concerned over this? Shouldn't they be documenting type, dosage, route etc and initialing those?
I have discussed my concerns with Dr's and Office manager, but I can not find WRITTEN documentation to support my concerns. Any information to support or dispute my concerns will be greatly appreciated. Thank you , su
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