Wiki documentation for nurse charges during office visit

[akaeb]

I was wondering when a pt comes in for an office visit and during that office visit a vaccine, strep screen, or influenza test is done does this information need to be included in the note? I was always under the impression if it's not in the note it didn't happen. I want to make sure I am doing everything correctly going forward.

thanks!!

 

[skiboi]

nurse documentation

In today's world of EMR/EHR you'd think if the nurse gave a vaccine that nurse would have to input that information into the chart. If a strep test or influenza test were done there would be an order from the provider, correct?
If I were auditing a note of course I'm going to have to put on my investigator hat and do some research to find that information to support the ancillary services performed. Off the top of my head I can't really think of a scenario that the nurse would have to really input written documentation into the note to support these services, someone else may have another opinion as my head hasn't been in family practice for a couple of years.
So in this case there should be input into the chart from the nurse supporting these services and that would hold up in court because there is an audit trail for all personnel in that chart.
Jeffrey