Pertinent vs. Nonpertinent vital signs

[rveneziano]

We just had a discussion in our office about Pertinent vs Non pertinent vital signs and I am looking for futher documentation about this. Let me know if you have more information I can present to providers.

 

[FTessaBartels]

1997 vs 1995 guidelines

If you are using 1997 guidelines you must document at least 3 vital signs to get ONE bullet point. You can document ANY three of the following seven:
1) sitting OR standing BP
2) supine BP
3) pulse rate and regularity
4) respiration
5) temperature
6) height
7) weight
Vitals may be measured/recorded by ancillary staff

If you are using 1995 guidelines, you can document any ONE of the above and get credit for constitutional. OR you can just say "NAD" and get credit for constitutional system exam.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Jagadish]

Even under 1995 guidelines, it would be better if at least 3 vitals are documented to be on safe side. These may be recorded by the ancillary staff but should be attested by the Physician.

 

[sbicknell]

Pertinent vs Non pertinent vital signs

Means of the 7 possible vitals (listed earlier) which is most important to record based on the patient's CC and ROS.

If a patient presents with palpatations it would be more pertinent/important to record pulse and respiration than it would be to record height and weight (non-pertinent)

Same if a patient presents for f/up of HTN, it would be more important/pertinent to record his BP standing/sitting than it would be to record his temp (non-pertinent)