Forum - Questions & Answers

May 19th, 2011 - dlartigue 3 

Requirements of the "Constitutional"

Using the 1995 Documentation Guidelines, what are the requirements for the Constitutional portion of the PE, and of the ROS?
In the 1997 Guidelines, 3 vital signs/can include appearance as 1 must be elicited before the Constitutional can be "counted".
Recently someone has mentioned only 1 vital sign under the Constitiutional in the '95 Guidelines needs to be elicited in order to meet the requirements and I am trying to confirm. Thanks!

May 20th, 2011 -

re: Requirements of the

The difference is that the 1997 Guidelines gave specific documentation requirements for exams, noted by bulleted exam items. The bullet for the Constitutional system specifically instructs that THREE of seven vital signs must be documented in order to give credit for that exam bullet.
• "Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5)temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
General appearance is noted as a totally separate exam bullet
• "General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

The 1995 Documentation Guidelines state only
"For purposes of examination, the following organ systems are recognized:
Constitutional (e.g., vital signs, general appearance)"


Because the do NOT specifically state a number of vital signs must be recorded, I would allow credit for any ONE vital sign recorded or any notation of general appearance.



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