Documentation of vitals in exam

Kiana

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That would be counted as constitutional, but what is considered stable would be the problem, did the physician want pt to return for BP check? It would be safer to document that. Vitals stables is like stating all other systems negative, but that is what the physician would document. If the nurse or medical assistant is doing the vitals these should be documented.
 

RebeccaWoodward*

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I agree. I asked a similar question on another forum and was reasurred with this excerpt. In your case, stable=normal (In my opinion).

From p. 10 of the 95 guidelines:



●DG: A brief statement or notation indicating "negative" or "normal" is sufficient

to document normal findings related to unaffected area(s) or asymptomatic

organ system(s).
 
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