Wiki vaccinations

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dawn1170

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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????
 
Yes, I have heard that saying and have seen it in writing but now that I need to reference it I can't find it. Do you know where I can find "written documentation" to support this?

Thanks
 
I Would Say It Does Not Have To Necessarily Be Documented In The Patients Note For That Day But Having It Noted Under Immunizations Or Having A Consent Form That Is In The Medical Record Would Be Good Enough. The Md Does Not Have To Spell It Out In The Chart. For Example In My Office We Have A Walk In Flu Clinic So Individuals Come In As They Please And The Nurse Gives The Vaccine. She Documents It In Their Immunization File And Files The Consent Form Away. Hope This Helps. Thanks Nicole Wessell, Cpc
 
Vaccinations

I agree with JWESS. As long as there is documentation of the flu vaccine being given, I would give credit and code for it.
 
I also agree that credit should be given for the vaccination...as long as there is a vaccination record and notation of the date given. It also helps if the nurse giving the vaccination notes the location given and lot # of the vaccine.
 
JWESS said:
I Would Say It Does Not Have To Necessarily Be Documented In The Patients Note For That Day But Having It Noted Under Immunizations Or Having A Consent Form That Is In The Medical Record Would Be Good Enough. The Md Does Not Have To Spell It Out In The Chart. For Example In My Office We Have A Walk In Flu Clinic So Individuals Come In As They Please And The Nurse Gives The Vaccine. She Documents It In Their Immunization File And Files The Consent Form Away. Hope This Helps. Thanks Nicole Wessell, Cpc
Click to expand...

My thoughts exactly....

Have a good day,
 
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