Wiki Vitals by RN

[sparkles1077]

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

 

[mitchellde]

The physician is suppose to repeat the vitals in his note for it to count. This is what I was always told. The only information the physician may "refer" to as reviewed is the ROS.

 

[sparkles1077]

Thank you! I would agree, but one of our senior auditors feels it should count.

 

[medicalsec]

THIS WAS FROM PALMETTO MEDICARE

Answer:
Ancillary staff may only document:

Review of Systems (ROS)
Past, Family and Social History (PFSH)
Vital Signs

These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can perform the History of Present Illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the Chief Complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

THANKS,

DEE