Open Forum

In our ambulatory clinics, staff will remove medication from our automated medication dispensing system (Pyxis) for providers to give during clinic procedures. If the licensed provider administering the medication is documenting in his procedure note, is the LVN/RN required to also document on the eMAR? Is it standard practice for the licensed provider to enter an order for routine medications used during the procedure that are documented in the provider note? 
Please share how you are managing this in your ambulatory clinics. 


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Jana Evenhouse
Los Angeles
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Our intent, Not sure it is happening consistently, is that the providers place the order and also document in the MAR. We are trying to relay that if the med is ordered and documented it will populate the note if the appropriate Auto text functions are set up. We do not desire duplicate documentation. Since the documentation on the MAR is the source of our billing data it must be documented on the MAR.

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Ray Snider DNP MSN RN NEA-BC
Senior Manager Clinical Operations
Emory Healthcare
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Our facility documents everything in the MAR that is given.  It is to be documented by the person whom administers the medication.  This ensures proper billing can be done for the medication.  It also allows easier, quicker access to pull a report if there is ever a medication recall.

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Amanda Pearce, RN-BSN
Clinic RN
Swedish Medical Group
Renton WA
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Jana, 

In our outpatient setting, nurses do document on the MAR and the option for administration is there "given by provider". The route, time, and other information is added by the nurse. The provider also documents what they gave and how in their note.

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Quiana Simmons
Metrohealth Medical Center
Garfield Heights OH
(216)509-5654
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In our clinic, nurse places the order, obtains medication, documents administration (as given or given by another),
and documents on MAR. The provider's note contains documentation of administration generated by nurse's entering a procedure note (that all becomes provider's note). If procedure is not done the medication appears on the note as given but the provider would need to include administration in note narrative.

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Lauren Leimbach RN
Centrastate Med Ctr
Morganville NJ
(732)610-4583
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In our clinic the  orthopedists administer intra- articulator injections. They document it in their note , however the RN scans the medication into the MAR. Our documentation platform is meditech, and  the nurse can enter the doctors name. The scanning of the medication is important for billing.

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Janette Morgan, MSN,RN,AMB-BC,HN-BC
Director Community Care,
The Valley Hospital,
Ridgewood, New Jersey,
973 427 7676
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Original Message:
Sent: 02-03-2023 08:50
From: Lauren Leimbach
Subject: Documentation of Medication when administered by MD in Clinic

In our clinic, nurse places the order, obtains medication, documents administration (as given or given by another),
and documents on MAR. The provider's note contains documentation of administration generated by nurse's entering a procedure note (that all becomes provider's note). If procedure is not done the medication appears on the note as given but the provider would need to include administration in note narrative.

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Lauren Leimbach RN
Centrastate Med Ctr
Morganville NJ
(732)610-4583
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