# Vaccinations



## dawn1170 (Mar 12, 2008)

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????


----------



## LOVE2CODE (Mar 12, 2008)

YES...If not documented, not done......


----------



## heathergirl (Mar 12, 2008)

I agree- it has to be requested by the Dr.  Any procedure, injection, or diagnostic test must be recorded by the Dr.


----------



## dballard2004 (Mar 12, 2008)

I totally agree.  There must be documentation to support the vaccine.  Otherwise, it can't be coded/billed.  Thanks.


----------



## dawn1170 (Mar 13, 2008)

That is what I thought, thanks for confirming it.

Thanks


----------



## dawn1170 (Mar 13, 2008)

Ok I have one more question, I need to find reference material to provide to the MD. I have read somewhere that it must be ordered and I can't find it. Do you know where I can find "written documentation" to support this?

Thanks for all your help


----------

