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It may be derived from work completed inthe microbiology lab, unitsdispensed from the pharmacy, administrations performed by nurses, expenditures produced from drug purchases, documentation within any area of the electronic medicalrecord, extraction from supplemental tools or data warehouses, and so much more.
Don’t get me wrong – I’m not suggesting that you don’t document necessary pieces of information in the medicalrecord, or that you don’t document your interventions. But for basic interventions like I just described, it makes the physician look good when they “fix up” orders based on your informal recommendations.
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