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Vitals Taken by the Nurse and Provider Credit

  1. Default Vitals Taken by the Nurse and Provider Credit
    Medical Coding Books
    In an EMR when a nurse documents vitals in the intake note does the provider have to comment on the vitals such as "vitals reviewed and are stable" in order for them to receive credit. Or do they automatically receive credit because they are authenticating the chart note. My concern about them not commenting and or documenting something such as "vitals as above" doesn't give me any idea whether or not they really reviewed them.

  2. #2
    I don't know if there is anything out there pertaining specifically to vitals in EMR.

    Generally, I give the providers credit for them even if they don't specifically state they reviewed them.

    The only time I don't give credit is if the vitals are not listed on the same page as the doctors note and they don't reference them.

    That is just how I handle it.

    Laura, CPC, CEMC

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