Injectable Administration Documentation
Documenting the administration of an injection
- Add the medication as an order in the Assessment and Plan.
- Select the "Administer" tab.
- Select "VIEW MORE" to populate the necessary fields.
- Document all required fields under "Details". The .injectionprovideradministered text macro should be used in the internal notes when the injection administered by ordering provider. If the injection is administered by certified MA under general supervision of the ordering provider, the .injectionMAadministered text macro should be used.
Additional Notes
- If completing the injection outside of an encounter, follow the above steps in an Order Group.
Related Articles
Provider – Encounter Documentation (Consult & Administration Appts.)
**If you want to refer a patient for Spravato use the order set “Referral Esketamine (Spravato)”. Once ordered the MA will properly coordinate a consultation**. Consult Encounter Documentation Consult scheduling: The following appointment types will ...(Spravato MA Workflow - Pre Administration (Prior Authorization, ordering, and Scheduling)
Spravato MA Workflow - Pre Administration Pre-requisites: Pre Auths: Autorization order must be submitted during the consultation appointment Insurnace information and card must be updated and current (within the year) Prior Authorization must be ...TOVA Documentation
Tova Documentation Tova documentation will require both Clinical Staff and Provider. Clinical staff will document the ADHD Testing (EP) for reason for visit and will complete the History of Present Illness. Clinical staff will also add TOVA results ...AMA Documentation
AMA Documentation Typically, in an outpatient mental health setting, AMAs are used when a patient declines a higher level of care. Typical Uses and Examples: o Adverse Medication Reaction (TMS, Spravato BP issues, or other treatments, or medications ...TMS Workflow: Treatment Documentation
Provider TMS Consult When a provider is documenting the TMS Consult, please reference the following workflow: Documentation Use TMS Consult Reason for visit Ordering TMS From a patient encounter place and sign the following order: Transcranial ...