Vitals Tracking & Management

Vital signs not only assist in early detection of potential problems, they aid in the monitoring and maintenance of ongoing medical conditions. The Vital Signs layout allows Enterprise Health users to view and add measurements of a patient’s essential body functions. Whether it is from within the Vitals chart tab or within the patient’s encounter, the body’s most basic functions can be measured and recorded, quickly and easily.

Adding Vitals to the Patient Encounter

1. To add vitals to a patient’s encounter, navigate to the Objective section of the encounter, open the Vitals
   subsection, and click the pencil
   icon, located on the right of the header. The Vitals section will expand. Note that previous vitals display at the bottom of the Vitals section.

2. With the Vitals section expanded, simply fill in the appropriate fields and use the dropdowns, adding comments, if necessary.
3. The observation Date/Time will automatically populate today’s date. If the information needs changed or made current, utilize the appropriate buttons, located to the right of the entry fields or free text.

4. When entering measurements, any blood pressure, respiratory, pulse, or temperature values falling out of range will produce an on-screen alert, giving the choice to modify.

5. Additionally, if BMI falls outside of a healthy range, the system will automatically prompt for a need of patient education and a potential Dietary Consultation. Clicking OK will allow the system to add the order to the visit encounter automatically.

6. After all vitals have been entered and comments added where necessary, simply click the Next button, and the following section will open, to allow for additional documentation.

Adding Vitals to the Patient Record

1. To add vitals to a patient record, utilize the edit feature from the Vital Signs portlet, on the Patient Summary landing page, or navigate to the Vital Signs chart tab of the patient.

2. Below the table of previously observed vitals are entry fields for the manual entry of new, or current, vitals.

3. Add all of the appropriate vitals, as needed, and note the Observation Date/Time. The system defaults the current date and time the Vital Signs chart tab was accessed.

4. Enter the appropriate free-text values for each measurement, using the dropdown selector to determine the unit of measurement. Comments may be made for each vital, if necessary. Use the tab key to move between fields quickly and easily.

5. Continue entering all necessary vitals. All fields DO NOT need entered in order to continue.
6. When entering measurements, any blood pressure, respiratory, pulse, or temperature values falling out of range will produce an on-screen alert, giving the choice to modify.

Once all the necessary values have been entered, click the
button. 8. Fields that include comments will load with an asterisk ( * ) next to the value. Using the cursor, hover over any value to see details, or hover over a value with an asterisk to see the comments and details.

Tip

When hovering over values, alternative results will display. In this example, inches can also be converted into centimeters. Also, if the user preference is Metric units, this can be configured from My Settings.

9. Click on any of the vitals to edit. After making the necessary updates or edits, click Submit. Otherwise, if the vital sign has been entered in error or entered incorrectly, click Delete.

10. If multiple days or instances of vitals need to be entered, go to the Vitals Flowsheet. At the bottom of the page, there is an Add Observations section. Enter the appropriate observation date/time and all necessary values. Click Add. Continue, until all instances are documented, as needed.

11. Once all the patient’s vitals have been added, click Submit.

View Vital Signs/Observations

1. Either navigate to the E-Chart sidemenu and search for and select the necessary patient, or utilize the Chart Search portlet.

2. Once in the patient’s E-chart, select the Vital Signs chart tab.

3. After selecting the Vital Signs chart tab, the patient’s previous vitals will display in table format. Reference Table 1.1 for the headings and their meanings.

TABLE 1.1

4. To open the Observations Search and view a date range of vitals, or to see specific vital signs plotted out or in a flowsheet format, click List Observations, above the upper-left corner of the table.

5. Entering a date range will limit the the displayed observations accordingly, and selecting a Flowsheet will limit the types of observations displayed, based on the type of Flowsheet chosen. Without a date range, select Vitals from the Flowsheet dropdown and all vitals will be displayed in the form of a Vitals Flowsheet.

6. With the desired Flowsheet selected, the patient vital signs will display at the bottom of the page.

Device Interface

Enterprise Health has the capability to interface with a vitals device such as Welch Allyn Spot Vital Signs Monitor.

1. With an established interface, there will be a Vitals From section within the Vital Signs chart tab.

   Simply click the
   button, and the vitals will import and store within the Enterprise Health system. Otherwise, click the Manual link, and the vitals can be entered manually, as needed.