I have the same question regarding focused exam documentation in regards to the vital signs. Our physicians use a electronic sheet that pulls in the vital signs information.
Tina Fickey, RHIT, CPHQ Physician Regional Medical Center 900 E. Oak Hill Ave Knoxville, TN Email: [email protected] Office: 865-545-8605 This is a confidential patient safety work product communication. It is protected from disclosure pursuant to the provisions of the Patient Safety and Quality Improvement Act (42 CFR, Part 3) and other state and federal laws. Unauthorized disclosure or duplication is prohibited. Disclaimer: This electronic message may contain information that is Proprietary, Confidential, or legally privileged or protected. It is intended only for the use of the individual(s) and entity named in the message. If you are not an intended recipient of this message, please notify the sender immediately and delete the material from your computer. Do not deliver, distribute or copy this message and do not disclose its contents or take action in reliance on the information it contains. From: Sepsisgroups [mailto:[email protected]] On Behalf Of Prabhakar, Brenda Sent: Wednesday, October 28, 2015 1:48 PM To: [email protected] Subject: [EXTERNAL] [Sepsis Groups] Vital Sign Documentation for Provider focused exam Hello, I have a question about the focused exam documentation requirements in regards to vital signs. I understand a complete set of vital signs needs to be included in one note. Our physician notes electronically pull in vital signs from nursing documentation that have times associated with each component. They are pulled in as a small chart with the time taken. Example: Temp 99.8 taken at 09:00, HR 110 and RR 24 taken at 10:00, BP 103/78 taken at 10:15. Would this pass the measure if the complete set of vitals are not all taken at the same time but are included together in one note? Thanks in advance for your feedback. Brenda Prabhakar RN BSN Sepsis Steering Committee Co-Chair Doylestown Hospital Doylestown, PA -------------------------------------------------------------------------- Disclaimer: This electronic message may contain information that is Proprietary, Confidential, or legally privileged or protected. It is intended only for the use of the individual(s) and entity named in the message. If you are not an intended recipient of this message, please notify the sender immediately and delete the material from your computer. Do not deliver, distribute or copy this message and do not disclose its contents or take any action in reliance on the information it contains.
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