Drug administration lack of documentation

In the A/P doctor ordered for decadron but was never indicated in the notes if the drug was administered. My question is can I assume that the drug was administered or should I just include this with the e/m for mdm since there was lack of documentation from the provider? I hope you can help me with this question. Thank you

re: Drug administration lack of documentation

If it was not documented, it is not defensible, therefore it never happened.