How To Record Vitals in Charting

This section helps in recording patient’s vital information such BP Systolic, Diastolic, Height, Weight, and so forth.

Some Important Vital Features

•Click the Growth Charts icon Growth-chart , Blood Pressure Chart iconBP-chart , and Glucose Chart icon Glucose-chart to generate the charts based on the vitals data recorded during different visits. Growth charges will not be generated for the patients older than 20 years.
•Click Capture Vitals to capture the vitals data using the external device. Contact the InSync PM/EMR support team to have this feature installed in your system.
•Once the vitals are reviewed, you can display the name of the reviewer along with date and time by selecting the Reviewed by check box.
•Click the icon info to view the details such as Created By, Created On, Modified By, and Modified On.

Recording Vitals in Charting

1.In the charting elements ribbon, click Vitals. The Vitals screen is displayed.
2.Enter the blood pressure values in the BP Systolic and Diastolic fields. Select an appropriate option from the drop-down list from where the blood pressure was measured.
3.Enter the Oxygen Saturation and an appropriate option from the drop-down list.
4.Enter the Respiration Rate.
5.Enter the Waist Circumference.
6.Enter the Pulse rate of the patient.
7.Enter the Height and Weight details. The Body Mass Index (BMI) and Body Surface Area (BSA) are calculated automatically based on height and weight data.

Note: For patients aged 3 and over, if you do not want to print BMI calculation on the PQRI report, select the Exclude BMI Calculation from PQRI check box by selecting the reason from the drop-down list next to the check box. This will help in increasing numerator for “Core 4: Record and chart changes in vital signs” of MU-2. Please refer to the above section in Meaningful Use Stage – 2 User Guide for more details.

 

8.Enter the Glucose Level recorded when fasting or non-fasting.
9.Enter hemoglobin value in HgbA1c.
10.Enter the Hip Circumference.
11.Select the Position of the patient when recording vitals.
12.Select the Temperature from the drop-down list.
13.Select the provider who performed the vitals from the drop-down list.
14.Enter the Head and Chest Circumference. This field is visible only for patients below or equal to 3 years.
15.Enter the additional details in Notes, if any.
16.The Body Mass Index, Body Surface Area and Ideal Body weight will be calculated automatically once required details are entered.
17.Click Save. The vitals data recorded are added to the grid.
18.The user can edit the Vital entries by clicking Edit icon from the grid.
19.The user can delete the Vital entries by clicking Delete appointment icon from the grid.