I am working with a practice whose physician only documents 3 vitals during a patient's physicial exam (and always the same 3: weight, BP & pulse). Ordinarily, this would be fine and would be appropriate to count for a bullet under the physical exam.

However, the problem I have is that sometimes the documentation states "about 80 lbs" or "per patient 250 lbs but appears much heavier". (The patients are not immobile.) This implies that a practice employee is not actually measuring and recording the weight.

My question is, should the patient's self-reporting of their weight (or any vital measurement) count or should all documented vital signs be measured/evaluated and recorded by a practice employee?

I would apprecite any written resources or links you can provide as I need reliable resources for my audit report. Thanks!!