This page will explain how to document patient Vital Signs.
Vital Signs
Vital signs are a critical part of documenting a patient's visit and are a part of both Meaningful Use Stage 1 and Meaningful Use Stage 2 criteria. It is a core measure of both.
Vital signs can be documented in one of two ways: from the Vitals icon on the patient's chart or by use of the «Vitals» link inserted into any other template, such as a dashboard or encounter form.
Record Vital Signs Window
Using either method mentioned above will open the Patient Information for Patient Name window, where new vital sign records can be added and previously documented records can be modified.
To add a new record:
- Click the green Add button.
- The Vital Signs pop up will open.
- Enter in the date recorded.
- Enter in Height/Length, selecting either inches or centimeters from the drop-down menu.
- Enter in Weight, selecting either pounds or kilograms from the drop-down menu.
- At this point, BMI will calculate automatically.
- Enter in Pulse, Respirations and Temperature as desired (note: these are not requirements for meaningful use).
- Enter in sitting or standing blood pressure.
- Click Save to finalize and save the record.
Linking to an Encounter
After entering a vital sign record, it is important to link this vital sign to its related encounter. Linking a vital sign ties this record to the date of service where the record was documented and is the trigger for this to count as part of meaningful use.
- To link a vital sign, click on the vital sign record from the list.
- Click the Link button in the upper-left hand portion of the window.
- Select the date of service from the available list.
- Click OK.
The vital sign record will now show as linked in the vitals view.
(ARCHIVED) Vital Signs for Meaningful Use
While this is no longer a requirement in Meaningful Use in 2015, the below video is left archived as a demonstration for documenting patient vital signs.
Video:
For the most up to date video on Meaningful Use, please click here.