Record Vital Signs for the Nurse Progress Note
- On the Vital Signs panel, click Historical information entered this encounter to view all vitals for the current encounter.
- Click History to view a complete history of the client's vitals.
- Click Add to add a new set of vitals.
The Vital Signs (Lite) - [New Record] template appears. The Measured date, Time, and Measured by fields are populated. However, the date and time can be manually changed but the user name in the Measured by field cannot be modified.
- Enter information using the on-screen numeric keypad.
- Click the NEXT button below the numeric keypad to enter information in the next field.
- Select the Carried forward option to pull a previously entered Height into this field.
- After a Height and Weight value are entered, a BMI value is calculated below the numeric keypad.
- Select the BMI Plan link to open the Health Promotion Plan template, where an out-of-range BMI can be easily addressed with diet, exercise, and referral information.
The Functional Status panel on this template provides a link to depression plans and other screening tools.
- Click Save and then click Close.
The saved information from today's encounter is the only data that appears in the Vital Signs grid.