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Comprehensive Error Rate Testing

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Medication Administration

Insufficient documentation means something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for medication administration. 

Incomplete Physician Order:  The physician who is treating the beneficiary must sign and date the medication order. The complete medication order must include the following:

    • Medication name
    • Dosage
    • Route of administration
    • Frequency of administration

Missing Medication Administration Record (MAR):  The MAR is the report that serves as a legal record of the drugs ordered and administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical chart. The health care professional signs off on the record at the time that the drug is administered.

Missing Medical Necessity Documentation: The documentation must support the medical necessity for ordering the medications and must be present in the patient’s medical record.

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