Unit Clerk/Secretary entering Vital Signs in EMR

[berniehoganrn]

Hi All! Just a quick question. When using an electronic medical record - how do you have Vital signs entered into the electronic medical record? I am asking for hospitals that do not have monitors that automatically send the vital signs to the EMR.

We currently have the medical surgical techs take the vital signs and document on paper. The tech informs the RN of any abnormal vital signs and then gives the Vital Sign Sheet to the Unit Clerk to enter into Meditech.

There were questions at a meeting today regarding whether or not this is OK?

They wanted to know if the unit clerk could enter the information even if they were not the person who physically took the vital signs.

Any input or feedback would be appreciated!

Thank you!

[Triddin]

It would likely have to be documented as "taken by..." Out of curiosity, why can't the tech enter the vital signs? If your unit clerks are anything like ours and swamped with work as is, I can only imagine adding vital sign entry on top of that

[MunoRN, RN]

Anyone can enter vital signs into an EMR, although when someone else is entering them a "taken by" note should be added.

[Buckeye.nurse]

Yep, what MunoRN said. The unit clerk entering vital signs is fine as long as they are charting who took the vital signs. About 7 years ago our EMR wasn't fully implemented. Doctors still wrote orders on paper, and unit clerks entered the orders into the medical record. They were just required to document who wrote the order.