recording vitals signs to support an e/m level

My question is this: in recording the height & weight of a patient as part of their vital signs requirement (to meet the 'constitutional' portion of an exam), does the provider/staff have to actually measure the pt's wt & ht, or can we just ASK THE PATIENT what their ht & wt are & record their answer?

I also need to know if your answer is an opinion-based answer or if it is based on official fact. If official fact, can you please quote your source? My supervisor needs to know...
THANK YOU!

re: recording vitals signs to support an e/m level

The documentation of vital signs is a required core measure for meaningful use and the CMS EHR Incentives for eligible professionals,or EP. The measure itself if very clear: “For more than 50 percent of all unique patients age 2 and over seen by the EP, height, weight, and blood pressure are recorded as structured data.” This measure can be excluded by: “Any EP who either see no patients 2 years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice”.

Even with that guidance questions still remain. What if an EP believes that only two of the vital signs are relevant? Can they just document those two? Do the vital signs have to be updated at every encounter? Are there ways for the vital signs to get into the EHR other than by the EP or staff? What if the patient is too sick to have height measured? For these questions we can thank CMS for the answers below:

¦“If an EP believes that one or two of these vital signs are relevant to their scope of practice, then they must record all three vital signs in order to meet the measure of this objective and successfully demonstrate meaningful use.”
¦“Height, weight, and blood pressure do not have to be updated by the EP at every patient encounter. The EP can make the determination based on the patient’s individual circumstances as to whether height, weight, and blood pressure need to be updated.”
¦“Height, weight, and blood pressure can get into the patient’s medical record as structured data in a number of ways. Some examples include entry by the EP, entry by someone on the EP’s staff, transfer of the information electronically or otherwise from another provider or entered directly by the patient through a portal or other means.”
¦“In cases where taking an actual height measurement is inappropriate, self-reported or estimated height can be used.”
Jim Tate is a nationally recognized expert on the CMS EHR Incentive Program, certified technology and meaningful use and author of The Incentive Roadmap® The Meaningful Use of Certified Technology: Stage 1.

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re: recording vitals signs to support an e/m level

It is best practice to measure. Asking the patient has the potential to result in inaccurate information entered in the medical record and incorrect calculation of their BMI.