Unique Original Articles » Documentation requirements for practice nurses administering vaccinations

There have always been a lot of concerns surrounding the issue of documentation requirements as it relates to immunisation. The recent spike in Medicare audits focusing on appropriate documentation and circumstances surrounding nurse MBS items (10993) have made this an even hotter topic.

Below is a breakdown of essential do’s and don’ts depending on the qualifications of the nurse giving the vaccination

RN Div1's and Medication Endorsed Div 2 Nurses (not credentialed Immunisation Providers)

These nurses can only administer medications and immunisations following a written order by a doctor. This means the General Practitioner must see the patient and add his own entry in the patient file as to what is to happen. (Medicare item 3 or 23).

The practicenurse may then administer the immunisation (item 10993). The General Practitioner must be in the building for the duration of the immunisation and for 15 minutes after just in case of an anaphylactic event.
The nurse must then make an entry in the patient file detailing what immunisation was given, as well as site of injection.

If the service is to be bulk billed and the patient is under 16 years of age or a commonwealth concession card holder then item 10990 can also be claimed.

Immunisation Providers (RN Div 1 currently holding a Nurse Immuniser credential)
These nurses can initiate immunisations as long as the it is part of the current immunisation schedule (cannot initiate travel vaccinations).

Immunisation Providers may give vaccinations without the need of a doctor in the building.

This nurse initiates immunisation from the schedule for the patient and gives the same.

The Nurse records encounter
Claim item 10993 (under the patient's usual provider) and 10990 if applicable.

When routine vaccinations are being provided by credentialed nurse immunisers, there is no need for the patient to see a medical practitioner, therefore, no other professional consultation item (e.g. 3, 23, 36) can be claimed by the GP unless a separate service not related to immunisation was also provided.

Whenever a professional attendance item is claimed (3, 23, 36, etc), there has to be written evidence of the details of the consultation (an entry in the patient file) made by the GP claiming the item.

Also note that nurse-related Medicare items only apply to those nurses holding a current registration with the nurses board in the state of Victoria.

These items must not be claimed by nurses not yet registered, medical students or other practice staff.

For further information go to http://www.practicenursing.info/education.htm
Article Source: JS2 Article Marketing