Multiple Vital Signs Entries per Visit

There are times when a second set of vital sign data needs to be entered for a patient and there is no place to record it. Most often, this is for a second blood pressure reading, but other vitals, such as temperature or pulse oximetry, might need to be repeated on a case-by-case basis.

In the software, the clinician is able to record the initial vital signs and then record subsequent readings for the same visit. The last vital sign values added for each type of biometric measure will be considered the "official" one for that visit.

You may preview this feature from the EMR Charting Workspace, by select the Record Vitals button.

 

EMR_Charting_Workspace

The [Enter Vitals Signs] window will display.

Enter_Vital_Signs

The top portion of the window is information which will not change, but the bottom part of the window now contains 3 new tabs.

SUMMARY: This tab will display (as in the past) and will be used when creating the Charting Note.

READINGS: A list of prior readings is displayed. This tab will allow additional readings to be added, changed, or deleted.

 

For example, a reading may be added by clicking the Add button. Users will enter date and time as usual and enter the new reading in whatever category they choose. In this case, the blood pressure and pulse were changed.

Enter_Vital_Signs

Notice the new numbers. Also, we have two new fields to further clarify the circumstances at the time of the reading.

Select OK to add the record. A message will display to ask if you want this newest reading to replace the Summary reading that will be used when creating the Charting Note. If you answer yes this new reading will populate the Summary information; will simply add it to the history displayed on the READINGS tab and capture PHI Auditing.

All of these readings can be viewed from the Patient Chart, CLINICAL RESULTS, as well.

NOTE: In Net Health Employee Health and Occupational Medicine, users have the ability to document more than one vital reading during a visit. The Charting Note will include all vital readings created for the visit. For more information please click here.

Print button

Click the Print button to generate the Vitals Reading report which details all of the vital readings recorded in a single visit for a single patient in descending order by date and time.