Do you have any tips for documenting drugs and biologicals?


For nurses, the emphasis on medical record documentation typically focuses on ensuring that the drug administration service has been adequately and correctly entered into the patient’s record. However, insufficient or absent documentation specific to the drug or biological can have a significant impact on reimbursement. Ensuring payment for the products administered starts at the point of order. Whether the encounter represents a scheduled, walk-in, or emergent visit, medical necessity documentation is key to ensuring coverage. Another key component of documentation is the correct recording of the volume dosed and any volume wasted. Documentation of waste is specifically important when the dose administered is from a single-dose vial.


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