When coding for the exam utilizing the '95 guidelines, when the urine input/output, respirations and pulse are documented within the vitals, is it appropriate to give credit for urine = GU, respirations = respiratory, and pulse = cardio? We have always considered this documentation to be part of the vitals and only to be used for constitutional. Below is an example:
EXAM
OBJECTIVE:
Most Recent Vital Signs:
BP 144/76 | Pulse 81 | Temp (Src) 97.9 (Tympanic) | Resp 22 | Ht 5' 5" (1.651m) | Wt 166 lbs 3.63 oz (75.400kg) | BMI 27.66 kg/m² | BSA 1.86 m² | SaO2 98%
Vital Signs Last 24 Hours:
Systolic BP: Systolic (24hrs), Avg:147 mmHg, Min:114 mmHg, Max:170 mmHg
Temperature: Temp Avg: 38.3 °C (101.0 °F) Min: 36.6 °C (97.9 °F) Max: 39.3 °C (102.7 °F)
Pulse: Pulse Avg: 96.5 Min: 81 Max: 118
Respirations: Resp Avg: 27.3 Min: 21 Max: 38
Intake / Output (Last 24 Hours):
Intake/Output Summary (Last 24 hours) at 01/07 0947
Last data filed at 01/07 0800
Intake 4779.8 ml
Output 4290 ml
Net 489.8 ml
Neuro: gait and function normal.
Thank you for your assitance on this.
EXAM
OBJECTIVE:
Most Recent Vital Signs:
BP 144/76 | Pulse 81 | Temp (Src) 97.9 (Tympanic) | Resp 22 | Ht 5' 5" (1.651m) | Wt 166 lbs 3.63 oz (75.400kg) | BMI 27.66 kg/m² | BSA 1.86 m² | SaO2 98%
Vital Signs Last 24 Hours:
Systolic BP: Systolic (24hrs), Avg:147 mmHg, Min:114 mmHg, Max:170 mmHg
Temperature: Temp Avg: 38.3 °C (101.0 °F) Min: 36.6 °C (97.9 °F) Max: 39.3 °C (102.7 °F)
Pulse: Pulse Avg: 96.5 Min: 81 Max: 118
Respirations: Resp Avg: 27.3 Min: 21 Max: 38
Intake / Output (Last 24 Hours):
Intake/Output Summary (Last 24 hours) at 01/07 0947
Last data filed at 01/07 0800
Intake 4779.8 ml
Output 4290 ml
Net 489.8 ml
Neuro: gait and function normal.
Thank you for your assitance on this.