Meaningful Use and Documentation of Vital Signs

Jim Tate, Meaningful Use Expert

Jim Tate, Meaningful Use Expert

Sometimes things are not what they seem. What can appear simple can become  complex upon closer examination. Lately I’ve been getting lots of good questions about one of the most cut and dried of meaningful use objectives, Vital Signs.

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.”