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
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