Document a Patient's Height, Weight, BSA, Temperature, Blood Pressure and Pulse

You can document a patient's height, weight, BSA, temperature, blood pressure and pulse using the Vital Signs panel.

1. Open NextGen® Enterprise EHR.
2. Select the Care Guidelines link on any of the main template.
   The Care Guidelines Paged View template opens.
3. In the Care Guidelines panel, select the Grid View link.
   The Care Guidelines grid view template opens.
4. In the Vital Signs panel, select Add.
   

   The Adult Vital Signs [New Record] template opens.
5. The Measured Date, Time and the Measured by fields fill in automatically.
   Note: You can change the date but you cannot modify the user name.
6. If you cannot document the vital signs, select the Unobtainable check box and make the appropriate selections from the list to document what was not attained.
   • The corresponding fields in the vital signs sections become unavailable.
   • The Exclusion and Non-Codified Exclusions links become visible.
7. If the patient restricted the measurement of certain vital signs, select the Patient Refused check box and make the appropriate selections from the Refused list to document what was refused.
   • The corresponding fields in the vital signs sections become unavailable.
   • The Exclusion and Non-Codified Exclusions links become visible.

   Note: The Exclusions link opens the Exceptions/Measures template where you can manage clinical quality measures exceptions for quality reporting. The Quality button opens the Exclusions information template. If you select the Unobtainable check box, a list enables you to select which vital signs parameters cannot be obtained. Select the Non-Codified Exclusions link to open the Exclusions template. To document an exclusion reason not related to quality reporting, select a Reason option and, then select an item from the corresponding picklist.
8. Document the Patient's Height:
   • In the Height/length measurements section, enter numbers in the ft and in fields.

     The values in the total in and cm fields appear automatically.

     Note: If you enter the height in the cm field, the values in the other fields appear automatically.
   • Select a Position option.
   • Select the Last Measured field to enter the date the patient's height that was last measured or select Measured today to automatically fill the field with today's date.
     Note: The template does not automatically search for a previous entry. If a previous entry exists, select the Carried forward option to use a value previously entered for height in the Height field.
9. Document the Patient's Weight.
   • Enter the weight in the lb field or kg field.

     Depending on which field you enter the weight in, the value in the other field appears automatically.

   • Select a Context option.
     Note: If you do not enter a height and weight on this template, a Body Mass Index (BMI) does not calculate for the encounter. Entering or carrying forward a previously entered height and entering a weight for today, causes a BMI status to display. If the BMI is out of the normal range (either too high or too low), a statement to this effect appear below the BMI. The BMI Plan link opens the Health Promotion Plan template where you can document a plan of care if the patient's BMI falls outside normal parameters. BMI is not available for patient's less than two years old.
10. Document the Patient's BSA.
    • Select the Calculate button to calculate the Body Surface Area (BSA), if needed.

      The calculated BSA value appears in the BSA field.

    • Select the Information button to open the Info Vs BSA information template, if needed.
11. Document the Patient's Temperature.
    • Enter the temperature in the F field or C field.

      Depending on which field you use, the value in the other field appears automatically.

    • Select the physical site used to take the temperature in the Site field.
12. Document the Patient's Blood Pressure and Pulse.
    • Enter the blood pressure reading in the Systolic and Diastolic fields.
    • Select a Position option and Side option.
    • Select the physical site used to measure the blood pressure in the Site field.
    • Select a Method option.
    • Select the appropriate Cuff size check boxes.

      The HTN Plan link opens the Health Promotion Plan template where you can document a plan of care if the patient's blood pressure falls outside of normal parameters.

    • Enter a value in the Pulse field.
    • Select a Pulse pattern option.