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Vitals - We are currently going to EMR

  1. Default Vitals - We are currently going to EMR
    Medical Coding Books
    We are currently going to EMR and the question came up regarding the nurses taking the vitals and the results blowing over on the physician note.

    In the paper world the nurses took the vitals and physician would have to state that results of three vitals to be counted as the constitutional in the exam. The question was asked if there could be a check box that stated the physician reviewed them and it would be counted by the physician for the constitutional exam. Please help clarify this.

    Thanks in advance,

  2. #2
    North Carolina
    The guidelines allow ancillary staff to record vitals...Was that your concern?

    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)

    Page 16 of the 97 guidelines
    Last edited by RebeccaWoodward*; 04-19-2010 at 11:12 AM.

  3. Default vitals
    I Knew they could be recorded by the nursing staff but wasn't sure if they could be counted as a part of the physician exam if he didn't restate them which would be redundant but have been told this in the past.

    Thanks for your help.


  4. #4
    North Carolina
    I have heard in the past that some auditors would not count the vitals if the provider did not reference them...i.e. Vitals WNL. Then why allow ancillary staff to record the vitals? Personally, I do think this is redundant documentation and I feel like I have a compelling argument with the DG's as a reference. Now...if the vitals were on a separate document (paper document), then I would stongly recommend that the provider refer to the vitals in his dictation.

    You may want to pose this question to your MAC for their view...

  5. Default Vitals
    I agree but wanted to see what others thought. Appreciate your help.


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