RevolutionEHR Insights ™

Release Notes have been moved to RevHelp

doc tips

How do you recommend documenting vital signs?
Posted: February 8, 2012

This has been an objective that has received a lot of discussion. To be clear: a provider can “exclude” out of this objective if ALL THREE vital signs are “not relevant to the provider’s scope of practice.” Some have stated that optometrists can readily exclude from this, but anyone who has followed my comments know that it is my recommendation that optometrists acknowledge their role as primary health care providers and document patient vital signs.

The vital signs are blood pressure, height, and weight. The HITECH rules cite a situation when a doctor might be able to accept patient self-reported height, such as when a patient is in a wheelchair. However, no similar citations exist for weight. When you also consider that we would never think that p…atient self-reported blood pressure is adequate documentation of vitals, it is my opinion that these numbers should be captured by measurement as much as possible.

Most practices have added commercial grade scales and height tapes on the wall in pretesting rooms. BP measuring devices were commonly in play in OD practices, although many have found the convenience of newer automated BP devices.

To make this measure, you must capture vitals at least once in the reporting period on at least 50% of unique patients. That means you might see a patient five times for glaucoma work-ups, but you would only need to document vitals once. Doctors who have attested to MU state that this isn’t a difficult objective.





View Status Page
Updates Prior to 2018