Wiki Pediatric E/M Coding

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cwilson3333

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How do you report ROS and Vitals on a pediatric patient, say a 2 year old?

And also a pre-teen, how is this information to be documented, i.e. do vitals need to be taken?

Our office is strictly orthopaedic, and we do see this age group quite often, especially for fracture treatment, or other injuries such as sprains. Most are new patients.

Thanks,
CW
 
ROS can be questions answered by the patient and/or caregivers. So the parents may say that the patient has not had any dizziness, shortness of breath, fever, nausea, etc. That counts as obtaining a ROS.

Vitals can be height, weight, blood pressure, O2 level, temp, BMI. Those things all count, and would be relevant for you.
 
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