Wiki IV Fluids Orders

[gwoodruff]

I have a chart that has the patient being given sulumedrol 25 mg IV in ED. We do not show an order in the record for this however it appears in the HPI. Can this be used in the MDM? And, does the order have to be in the chart? Please advise... Thank you so much in advance!

 

[LTibbetts]

I would send it back to the provider so that they can ammend the record. Then I would use it in the MDM.