Documenting a medication given by a physician

[KalipsoRed21, BSN, RN]

So let's say a doctor put in an order for a med. Tells you he gave the med and please document. I document that the provider states he administered this medication. 
I have tried not documenting it and then billing comes back and says they can bill for the med unless it is documented....they send the notification to the MD and he sends it to me.

My supervisor has told me before how our clinic has not been billing for meds appropriately and since we loose so much money due to this, we can't have more staff. Now I know this is *** but it is what is said.

I guess what I'm asking is, am I in more trouble for documenting a medication I was told was given (making note in the comment section that the physician states it was given but this RN did not witness) OR not documenting the med at all?

Opinions welcome.

[JKL33]

Agree with marking the med as administered and noting in the comment section that the med was reported as given by Dr So-and-so at X time. 
 

No doubt someone somewhere with too much time on their hands could make some argument about this but it isn't something I would lose sleep over. 
 

IMO it's a way bigger problem to not document it at all, since the primary function of the EMR is to serve as a record of events related to the patient's healthcare. 
 

$.02

[KalipsoRed21, BSN, RN]

JKL33 said:

Agree with marking the med as administered and noting in the comment section that the med was reported as given by Dr So-and-so at X time. 
 

No doubt someone somewhere with too much time on their hands could make some argument about this but it isn't something I would lose sleep over. 
 

IMO it's a way bigger problem to not document it at all, since the primary function of the EMR is to serve as a record of events related to the patient's healthcare. 
 

$.02

That's what I think, but manager said greater liability in documenting it in the MAR under administration even with the comment. I guess I can just put it in a note....surely some other *** will have a problem with that. ?

[mmc51264, BSN, MSN, RN]

In EPIC, we have an option to select "given by other" and then can put in a note who gave it. 

[JKL33]

KalipsoRed21 said:

That's what I think, but manager said greater liability in documenting it in the MAR under administration even with the comment. I guess I can just put it in a note....surely some other *** will have a problem with that. ?

This person does not know what s/he/they are talking about. Seriously. There is very little if any "liability."

Sometimes when I've run into thinking like this I ask what kind of liability. But when I didn't have the energy to engage in such a painful conversation I just say okay then do what I think is best anyway.

[KalipsoRed21, BSN, RN]

JKL33 said:

This person does not know what s/he/they are talking about. Seriously. There is very little if any "liability."

Sometimes when I've run into thinking like this I ask what kind of liability. But when I didn't have the energy to engage in such a painful conversation I just say okay then do what I think is best anyway.

Yes, I do that too. I' m just tired of the Poole who are suppose to be able to provide problem solving skills and guidance being less experienced than me. But I sure as *** don't want to be a manager. They are abused more than staff, and for what? A modest pay increase? Please.

[EmergentAnesthetics]

In the ED, many medications are administered by the physician or PA/NP. For example, propofol for conscious sedation or lidocaine for local blocks. I scan them under my name but make a note of "administered by -insert name and title-"

[abbnurse]

JKL33 said:

Sometimes when I've run into thinking like this I ask what kind of liability. But when I didn't have the energy to engage in such a painful conversation I just say okay then do what I think is best anyway.

I just love this so much .   This is exactly what I do !  And I completely love the fact that you described it as a " painful conversation".  It make me laugh , thank you !  ?  

[AGNPeaches]

From my experience epic has the most user friendly interface. In the intraprocedure tab particularly it's very easy to mark a medication as given and then change the ordering and administering parties.