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vitals taken by nurse

  1. #1
    Default vitals taken by nurse
    Medical Coding Books
    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?
    Thanks!

  2. #2
    Location
    Modesto, CA; Central Valley Chapter
    Posts
    225
    Default
    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)



    Quote Originally Posted by terese74 View Post
    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?
    Thanks!

  3. #3
    Default Vitals By RN
    I'm seeing different answers regarding this. I deal strickly with EHRs. The vitals are sometimes recorded by the RN separately from the physician documentation. If the physcian does not state vitals reveiwed/vitals reviewed by RN/or vitals reviewed per chart we are not allowed to count the vitals under the consitiutional portion of the exam. I do not see how vitals can be counted under exam if they are not directly referenced. The second scenario I've seen is RN documents vitals on the same record as the physician. Since the physician signs the documentation, the vitals can be counted as consitutional. I'm aware of both the 95 & 97 guidelines. So not sure.

  4. Default
    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.

  5. #5
    Default Vitlas By RN
    Tha'ts what I was told too.

    Quote Originally Posted by codegirl0422 View Post
    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.

  6. Default
    I would answer your question as no to non-EHR/EMR visits. 97 guidelines states may be measured and recorded by ancillary staff but exam can not be done by ancillary staff. I understand as they can take blood preasure etc and that the doctor does not physicially have to. But since ancillary staff can not do the exam, he must make reference that he reveiwed it. Also, if they are recorded on a log sheet in the chart, I believe Medicare requires that the physician initials or signs & date the log sheet for verification he reviewed them. I apologize but I can't find documentation on that.

    I would answer your question as yes to EHR/EMR visits per my previous reply.

    Hope this helps.


    Quote Originally Posted by codingangel View Post
    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)

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