Can you use the vitals that the nurse takes as a point in your exam even if the physician doesnt refer to them or repeat them in his dictation?
I have always been told that the doctor has to reference that they were reviewed. But with EHR records, I have heard in local meetings that you can count them due to when the doctor signs (finalizes) the visit, he has reviewed all of the visit. My understanding why they have to be referenced when not EHR is that alot of the time, the vitals is on a separate page/part of the patient 's file, and the doctor may not sign the completed visit till they receive back from dictation. This is my understanding of the rule. Hope it helps.
The answer is yes, here is the information from the 1997 guidelines:
Constitutional C Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
C General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)