Wiki Nurse Visit Documentation

Blairs, VA
Best answers
If a patient presents for a dressing change that is non surgical what kind of documentation is needed for the RN to charge a 99211 under the supervising provider? Do the vitals need to be recorded or just the information revelant to the dressing change? This has always been debated in our clinic if we need to get weight,temp and BP when they are only here to remove bandage and replace bandage. The time spent doing this is usually between 5-10 minutes
You are not required to have vitals for the visit, unless it is important for this particular patient. You can identify how the wound looks, a temp if this has been a problem for him, amount of drainage and the re-application of the dressing. Note any instructions given.