Wiki Vitals - Do vitals have to be taken

[cwilson3333]

Do vitals have to be taken on follow-up visit?

Sometimes docs don't dictate the 3 vitals on new patients, but some of that info is on patient registration sheet, i.e. height, weight

Thanks for any and all responders.

CW

 

[Evelyn Kim]

you seem to be posing 2 questions, for a followup vitals are not rquired, to establish a visit level you only need 2 of 3 elements. For new patients you need 3 of 3 so vitals would be needed. I would not take it from the registration sheet, it needs to be incorperated into the progress note for the visit.

 

[dclark7]

Vitals are part of the exam (although they can be documented by ancillary staff) so they do not have to be documented, this will affect your exam level. Any information taken from the pateint history cannot be used in the exam, it can be used for ROS or history as long as the provider reviews the info with the patient and documents that it was reviewed.