Internal Medicine Coding Alert
Reader Question:
Documenting a Nurse Visit
Published on Mon Nov 01, 1999
Question: What is the best way to document a nurse visit? Is a little narrative of what was done sufficient? Do you need to take vital signs?
Anonymous MA subscriber
Answer: A short and sweet writeup is OK, but there are certain things that should be included in order to substantiate the visit. You should document the blood pressure check, patients weight, any reactions to current medications, and any other services not usually provided by the physician.
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