11.x to 11.2 Review and Redesign Vital Sign Panels
Review and Redesign Vital Signs:
Two of the main core objectives in Meaningful Use are related to Vital Signs and Smoking Status. Storing this data incorrectly will not enable you to report the quality measures successfully. This data is essential to the make up of a patient’s medical record and in turn essential to the Meaningful Use criteria.
Meaningful Use states that more than 50% of patients older than age 2 must have their vital signs recorded and charted within their medical record. These “Vital signs” are made up of Height, Weight, Blood Pressure, Calculated BMI and Growth charts created from the collected data of children age 2-20. If you have created an entry for Smoking Status in the vital signs area you will NEED to discontinue this and collect this data only as a reportable item in another section of the patient chart, i.e Active Problems or Social History. The Vital Signs collected for every patient are not considered reportable items and therefore their necessity for Meaningful Use is strictly as “recorded data”. Recorded Data in Meaningful Use and in V11.2 terms, is essentially data you have the ability to enter in freely every time your patient comes in for a visit resulting in a better medical record for your patient.
Many times the patient will refuse to have their height and weight recorded; in these cases it is still important to have a comment area within your vital signs to note this. Refer to the External Wiki on how to add this option. Add Comment Box to Vital Sign View
Smoking Status now must be a reportable entry for Meaningful Use criteria. This means that Smoking Status must be documented in a form that can be reported for 50% of all patients aged 13 and older. Recommendations are to place your smoking status into Active Problems, V10 or V11 Note, or Flowsheet using Medcin. The current Meaningful Use guidelines for smoking status focus less on the clinical data of the patient smoking, i.e frequency and quit date and more on the patient current smoking status. Further documentation of the patient's smoking status and clinical relevance can be put into areas such as Social History.