Wiki Documentation time for Vitals

[Ltoth]

I have a question in regards to vitals being entered before the patient is seen. For example two hours before. I do not believe this to be compliant but I was wondering what others may know. I read at some point for my CPMA
that anything done before the patient was seen was not compliant. I can't find this particular piece of information. It was a question under the chemo section of one of the practice tests. If anyone could shed some light, I'd sure
appreciate it.
Thank you,
Lisa

 

[SharonCollachi]

What do you mean by "before the patient was seen"? The vitals are normally entered before the provider sees the patient. For chemo, usually an RN is the one "seeing" the patient, so if an MA is taking vitals before the RN starts the IV, how are they supposed to be documented if they are not entered?

 

[Ltoth]

I have a question in regards to vitals being entered before the patient is seen. For example two hours before. I do not believe this to be compliant but I was wondering what others may know. I read at some point for my CPMA
that anything done before the patient was seen was not compliant. I can't find this particular piece of information. It was a question under the chemo section of one of the practice tests. If anyone could shed some light, I'd sure
appreciate it.
Thank you,
Lisa

Hi Sharon,
My apologies, I was not clear on this. I have a pt. that has the vitals entered into the chart two hours before the patient is seen.
In my CPMA training, as a question in the Chemo portion, there was a statement that you could not enter information into the chart (i.e.) the nurse putting in the meds,etc until the patient was seen. (I am currently searching for this question in my CPMA studies). The question is: Is it compliant for vitals to be entered before the patient is seen? I believe they are taking them from the prior visit. Since we are now adhering to 2021 guidelines, is this even an issue?

 

[thomas7331]

Simply put, it is never compliant to falsify the medical record. I don't think this is something that affects coding, however if you are seeing something in the documentation that is obviously incorrect information in the medical record - i.e. entering vital signs that were not and could not have been taken yet - then I would definitely take action on it or bring it to someone's attention. That is actually a very serious matter which could jeopardize the patient's safety and shouldn't be tolerated.

 

[csperoni]

I agree this is more a compliance issue than a coding issue. Particularly for chemo, dosing for many meds is based on BSA and simply "taking them" from a prior visit could impact patient care. You wouldn't want to administer chemo if the patient has a fever of 102, but the chart said 98.8 because that's what the vitals were last time. In fact, if they are always taking from previous visit, which was taken from previous, which was taken from previous, etc. , those vitals could actually be months/years old. Nothing should be entered if it was not actually done.

Actual taking and documenting of vitals (usually by only a few minutes) prior to patient being seen by clinician is a standard practice, and I can't imagine any issue with that.