sparkles1077
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If vitals are recorded separately by the nurse and placed in the record, does the doctor need to initial and sign off to be able to count this toward the physical exam? The doctor dictates, but there is no evidence the doctor reviewed this information. Or can it automatically be counted as a constitutional element under physical exam?
Thank you
Diana, CPC
Physician Coding Auditor
Thank you
Diana, CPC
Physician Coding Auditor