M17.11 - Unilateral primary osteoarthritis, right knee

Clinical Definition

Vital signs monitoring includes measurement and recording of temperature, blood pressure, pulse rate, respiratory rate, and pulse oximetry. It may also include height and weight measurements, depending on clinical context.

Documentation Requirements

• Must document frequency of measurements (e.g., q4h, q8h, daily)

• Must specify which vital signs were monitored:

  • Temperature

  • Blood pressure

  • Heart rate/pulse

  • Respiratory rate

  • Pulse oximetry (if applicable)

• Must indicate if monitoring was:

  • Routine

  • Critical care

  • Post-operative

• Duration of monitoring period

• Any significant deviations from normal ranges

• Clinical reason for monitoring

Common Synonyms

• "Taking vitals"

• "BP check"

• "TPR" (Temperature, Pulse, Respiration)

• "Checking stats"

• "Basic measurements"

Coding Conflicts

Excludes1:

• Critical care vital sign monitoring

• Post-operative vital sign monitoring

• Continuous electronic monitoring during labor

Excludes2:

• Hemodynamic monitoring

• Cardiac telemetry monitoring

Scribing.io Automation

The AI scribe automatically detects:

• Numerical values associated with vital signs

• Time stamps of measurements

• Frequency patterns in documentation

• Normal vs. abnormal readings

• Links vitals to specific clinical contexts

• Auto-populates vital sign flowsheets

The system flags missing required elements and prompts for completion of documentation gaps in real-time.