Document Vital Signs

You can document vital signs for the patient on the Vital Signs Lite template.

Note: To document numeric values for height, weight, temperature, pulse, and respiration quickly, enter the values using the number pad. Click Next to move to the next field.

Click Add below the Vital Signs grid.

The Vital Signs Lite template opens.
To document unobtainable vital signs, select one of the following check boxes, and then select the vital signs that were not obtained from the list.
- Unobtainable
- Patient Refused
By default, the Measured date and Time fields display the current system date and time. Click the Time field to select a value to enter vitals measured at an earlier time.
By default, the current user information appears in the Measured by field and cannot be changed.
To enter Height, do the following:
- Record the height in the ft and in fields or in the cm field.
  The Last measured field displays the current system date when you enter height information. The value for height is carried forward to future encounters.
  
  You can enter height in metric units (centimeters) or standard units (feet and inches) and the other units automatically calculate and appear in the corresponding fields.
- Select the Position of the patient, Standing or Lying. If the patient’s height was previously recorded, choose Carried forward.
Do the following to enter Weight:
- Record weight in the lb field or kg field.
  The value for weight must be entered each time. When you enter weight in metric units (kilograms) or standard units (pounds), the other units are automatically calculated and appear in the corresponding fields.
- Select the context of the patient, Dressed without shoes or Dressed with shoes.
  Note: The BMI (Body Mass Index) for the patient automatically calculates when both the Height and Weight are entered. If the patient’s BMI is greater or lower than the recommended BMI range for the patient’s age group, an message appears. BMI is not available for patients less than two years old.
To create a BMI Plan for patients who have an out-of-range BMI, click the BMI Plan link.
Enter the patient's Temperature in the F or the C field and then enter the Site.

You can enter the temperature in metric units or standard units. The system automatically calculates and displays the other units.
Document the patient's Blood pressure:
- Enter the systolic and the diastolic values in the Sys and Dias fields, respectively.
- Document details about the blood pressure reading: Position, Side, Site, Method, Cuff size.
Note: If the systolic or diastolic values are abnormal, the BP is out of expected range. Further review is indicated alert appears. The system is packaged with the recommended JNC 8 guidelines. You can configure multiple entries for blood pressure values and alerts. For more information on how to configure vital sign alerts, go to NextGen Healthcare Success Community and download the latest Vital Signs Configuration Practice Template for NextGen® Adaptive Content Engine.
Enter the Pulse and the Pulse pattern.
Click the Respiration field and type a value or enter a value using the on-screen numeric keypad.
Document the Pain score and Method.

You can document vital signs for the patient on the Vital Signs Lite template.

Note: To document numeric values for height, weight, temperature, pulse, and respiration quickly, enter the values using the number pad. Click Next to move to the next field.

Click Add below the Vital Signs grid.

The Vital Signs Lite template opens.
To document unobtainable vital signs, select one of the following check boxes, and then select the vital signs that were not obtained from the list.
- Unobtainable
- Patient Refused
By default, the Measured date and Time fields display the current system date and time. Click the Time field to select a value to enter vitals measured at an earlier time.
By default, the current user information appears in the Measured by field and cannot be changed.
To enter Height, do the following:
- Record the height in the ft and in fields or in the cm field.
  The Last measured field displays the current system date when you enter height information. The value for height is carried forward to future encounters.
  
  You can enter height in metric units (centimeters) or standard units (feet and inches) and the other units automatically calculate and appear in the corresponding fields.
- Select the Position of the patient, Standing or Lying. If the patient’s height was previously recorded, choose Carried forward.
Do the following to enter Weight:
- Record weight in the lb field or kg field.
  The value for weight must be entered each time. When you enter weight in metric units (kilograms) or standard units (pounds), the other units are automatically calculated and appear in the corresponding fields.
- Select the context of the patient, Dressed without shoes or Dressed with shoes.
  Note: The BMI (Body Mass Index) for the patient automatically calculates when both the Height and Weight are entered. If the patient’s BMI is greater or lower than the recommended BMI range for the patient’s age group, an message appears. BMI is not available for patients less than two years old.
To create a BMI Plan for patients who have an out-of-range BMI, click the BMI Plan link.
Enter the patient's Temperature in the F or the C field and then enter the Site.

You can enter the temperature in metric units or standard units. The system automatically calculates and displays the other units.
Document the patient's Blood pressure:
- Enter the systolic and the diastolic values in the Sys and Dias fields, respectively.
- Document details about the blood pressure reading: Position, Side, Site, Method, Cuff size.
Note: If the systolic or diastolic values are abnormal, the BP is out of expected range. Further review is indicated alert appears. The system is packaged with the recommended JNC 8 guidelines. You can configure multiple entries for blood pressure values and alerts. For more information on how to configure vital sign alerts, go to NextGen Healthcare Success Community and download the latest Vital Signs Configuration Practice Template for NextGen® Adaptive Content Engine.
Enter the Pulse and the Pulse pattern.
Click the Respiration field and type a value or enter a value using the on-screen numeric keypad.
Document the Pain score and Method.

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