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Wiki Recording vitals

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GAcoder

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How important is it for doctors to record vitals? I remember it was important for meaningful use with EMR a few years ago. But, is it a requirement in encounters?
I code many charts that do not have vitals recorded and makes me wonder what the rules are. Thanks for any help.
 
GAcoder said:
How important is it for doctors to record vitals? I remember it was important for meaningful use with EMR a few years ago. But, is it a requirement in encounters?
I code many charts that do not have vitals recorded and makes me wonder what the rules are. Thanks for any help.
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I've never come across anything stating that vitals must be documented. As part of the physical exam, it is up to the provider to determine whether or not each of those bullets are medically necessary for each individual patient. If (s)he feels it isn't really necessary/relevant, I'm not aware of any issues with the lack of.

HTH!
 
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