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Thread: Documentation of vitals in exam

  1. #1

    Default Documentation of vitals in exam

    AAPC: Back to School
    Is it ok to say vitals are stable? Is this countable on the audit sheet using 95 guidelines?

  2. #2
    Join Date
    Apr 2007


    That would be counted as constitutional, but what is considered stable would be the problem, did the physician want pt to return for BP check? It would be safer to document that. Vitals stables is like stating all other systems negative, but that is what the physician would document. If the nurse or medical assistant is doing the vitals these should be documented.
    Kiana CPC, CPC-H, BCS-M, BCS-R

  3. #3


    I would count vital signs stable as constitutional for 95.

    For 97, you'll need to specifically state 3/7 to get credit.

  4. #4
    Join Date
    Apr 2007
    North Carolina


    I agree. I asked a similar question on another forum and was reasurred with this excerpt. In your case, stable=normal (In my opinion).

    From p. 10 of the 95 guidelines:

    ●DG: A brief statement or notation indicating "negative" or "normal" is sufficient

    to document normal findings related to unaffected area(s) or asymptomatic

    organ system(s).

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