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
- ICD-10 Training
- Exam Preparation
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join