Wiki Progress note needed when just an immunization given?

KolarSue

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Hi my question is this;

Is a progress note, signed by a provider, needed in order to bill out an immunization when the patient comes in for the purpose of an immunization only. This is not done as part of an office visit; they are only on the nursing schedule for the injection. An order would already have been written at a previous visit for the patient to receive the immunization(s). Entries are also made into the patient’s immunization record which include the type of shot, date the shot was administered, who administered the injection, location injection given, along with the drug manufacturer, lot number, and immunization dosage.
My thought is that since all of this information is recorded, the patient can now just come in for the injection and leave.

Thoughts?
Thanks!
 
As long as the order has already been placed and signed, there is no need for an additional note from the provider. The nurse note for the immunization is all that is needed.
 
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