Integrated Assessments: Vital Signs

Record the patient's Vital Signs (blood pressure, temperature, pulse, respiration, and O2 saturation) under the Doctor's Orders tab, Med Log tab, and/or any evaluation form with patient.vital_signs field.

Not seeing Vitals as an option? Check out this article on configuring integrated assessments. 

Required Roles: Integrated Assessments can only be logged by Super Admins, Record Admins, Doctors, Nurses, and Techs.

Doctor's Orders

The Doctor's Orders tab on the Patient Chart allows you natively record vitals. The name of this tab can be customized per organization, so this is the tab setup as Orders in the Patient Processes settings.

Let's review how to log Vitals:

1. From the patient chart, open the Doctor's Orders tab.
2. The top of the page allows a quick snapshot of the patient's integrated assessments.
3. Click the + icon next to Vitals.
4. Complete the Vitals entry. You can leave any of the fields blank if you do not have all the data available.
5.  If you've configured the system to alert you when patient results fall outside of the normal range, you'll see a red note under each item that is abnormal. 
6. Click Submit.
7. The section updates to display the recently logged information.
8. Click on the History (clock) icon to view a full list of the patient's past vitals entries.
9. From this pop-up, you can view the vitals log details including who logged the result and when.
10. Super Admin can delete logs created by mistake. The logs will be hidden but still available under Show Deleted button.

Med Log

The Med Log tab (often called MARs or MORs) on the Patient Chart allows you record Vitals entries, just like the Doctor's Orders tab. The name of this tab can be customized per organization, so this is the tab setup as MARs in the Patient Processes settings.

Please review the steps above to add a Vitals entry.

Evaluation

Vitals can also be documented in any Evaluation form where the patient.vital_signs field is included. You will also be able to view the patient's documented vitals history. Click here for more information on editing Evaluation Templates.  

From the Evaluation, document the patient's vitals using the available fields. You can also adjust the Date/Time if you made the measurements earlier. By default, the field and time will populate the current time.

The system will notify you if the numbers you are entering are abnormal (highlighted red).

You can click the Hx button to view the patient's past vital history. Alternatively—if the patient.vitals_signs_current field is added to the evaluation—the patient's most recent vitals stats will automatically display. 

Report on Vital Signs

The History Report allows users to get historical data for patient vitals across the board.