Wiki Vitals Documentation

[cwilson3333]

Do 3 vital signs have to be taken for every visit, new and established, including post-op patients and then recorded by treating physician in the EHR.

On new patients, vital statistics, i.e. height, weight, etc are completed on the registration form by the patient. Does the physician then have to make that part of his dictation.

Thanks for any and all replies,

CW

 

[mitchellde]

Vitals do not have to be taken at any visit , however it cannot count as an element of exam until they are taken and recorded by the provider in his note for that encounter.

 

[Texascoder64]

Cwilson333
are you referring to the 3 vitals pertaining to meeting stage 2 MU?

If so, I just posted this question in another heading "under Dermatology" since this was my question for what is relevant to Dermatologists for the core measure vital signs.

I would be curious about this to hear from others in specialties (like Dermatology) where taking vitals are not relevant in their practice. I am getting mixed info about just report BP not HT/WT and get an exclusion, etc... kind of confusing.

Thanks
Lisa Tompkins, CPC