I have a question that I hope I can get assistance with.

As I go through a patients progress note the physician will say something like “patient needs B12 injection”. It is not documented that the patient actually received the injection in the progress note. When I look in another part of the EHR to see if there is an order for the B12 and it is notated that the patient received it, is that documentation in the separate part of the EHR good enough to add the charge for the B12 or should I send a query and request for the information to be added to the progress note.

I know the statement ‘if it’s not documented it wasn’t done’ but how does that pertain when it is documented somewhere else. I’ve also seen this situation with immunizations, supplies that are given and certain procedures.

Thanks for the help