All infusion notes need to be signed and dated by the nurse, and if not, by the physician. There must be an order signed and dated by the physician. Additional items that should be included in the documentation include:
- Date of service;
- Patient weight;
- Dosage that will be given;
- Why the particular dosage was given;
- Actual start time of the infused drug;
- Actual stop time of the infused drug;
- Patient improvement; or
- Patient lack of improvement to support medical necessity of increasing the dosage.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.
