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Thread: Vitals Signs: Afrebile. Vital signs unremarkable

  1. #1

    Default Vitals Signs: Afrebile. Vital signs unremarkable

    Hi,

    (1995 guidelines) Vital Signs stable - count as Constitutional exam? As an auditor, I prefer to have the vitals listed (at least one [i.e. vitals: Temp 98.3...) instead of vitals stable and/or unremarkable. For all of you auditors out there...would you "count" vitals stable??


    P.S. I looked in the forums to see if this has been posted before, but I was not able to find any. If there is one, I apologize in advance =)
    Last edited by 1071471; 06-01-2010 at 05:58 PM. Reason: forgot to mention - 95 guidelines

  2. #2

    Default

    For me, I would not give him the bullet. Certainly not under the 1997 and I still would not under the 1995. I consider this very lazy documentation. What vitals? What results?

    "Stable" to me indicates that there is a comparison or a change. Were they unstable and now stable? What and who defines stable?

    If the nurse/tech documented the vitals (BP, temp, HR etc) then I would expect a statement from the physician "vitals reviewed and found within normal limits"

    If he did the vitals himself, then he should specify which vitals and the results

  3. #3
    Join Date
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    Default 1995

    If using 1995 guidelines I would give credit for "Vital signs stable" - AS LONG AS they were recorded somewhere in the chart for that DOS (usually the nurse records).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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