Vital sign Documentation In ER

[jollymon16]

Our ER prints off the vital sign trends from the monitor and puts a patient label on it and uses this for vs documentation. this is the first place I have been that does this, typically vital signs must be hand written, mostly to prove the nurse actually looked at them. How is it done in your ER? I would like to move to hand written vitals.

[Sun0408, ASN, RN]

With everything going to electronic charting, I don't see this happening. We had to validate our vitals that were electronic as a way to prove we saw the vitals. The monitors converted the vitals from the monitor to the our computer system then we had to select the vitals and accept. The date, time and our electronic signature was attached just like any other type of documentation. It worked really well.

[Altra, BSN, RN]

What you're describing would be a technological step backwards ... and what does it accomplish to have nurses manually record vitals as a stand alone task? Intervention based on vitals is what tells the story of nursing care -- not just the recording of data.

[jollymon16]

We are a little behind in the EMR race. We are going to all electronic medical records in May 2015. right now only Triage is done on computer-an old meditec system at that.

The problem I see with printing the vitals is that our nurses tend to not look at the vitals they print. we have some good nurses but have not had leadership to deal with any issues for many years.

[BrooklynRN11201]

not to mention relying on the monitor for accurate vitals - I feel the human component is necessary for documentation of vitals, though it is time consuming. our EMR allows PCTs to document vitals and we approve them in the system, therefore documenting that we saw them.

[Altra, BSN, RN]

The problem I see with printing the vitals is that our nurses tend to not look at the vitals they print. we have some good nurses but have not had leadership to deal with any issues for many years.

Technology will not solve that problem. Commitment to quality care and pride in performance is what is needed there.

[Anna Flaxis, BSN, RN]

Most of the time, I record vitals manually on the flow sheet, but every once in a while, when you have a critical patient and you're doing vitals every five minutes for two hours, it's a heck of a lot easier to print out the monitor report. It doesn't mean I haven't looked at the vitals. Believe me, I've been paying very close attention to them. It's just that I've had more urgent matters to attend to than writing down vitals that are already being recorded. Things like giving titrating sedation, sticking tubes into orifices, doing chest compressions....you know, little things like that.

[Rhi007]

What you're describing would be a technological step backwards ... and what does it accomplish to have nurses manually record vitals as a stand alone task? Intervention based on vitals is what tells the story of nursing care -- not just the recording of data.

So if I took a patients pulse on one wrist and had the oximetry probe on a finger on the same hand but the readings are different I would go with the manual reading. Same goes for BPs and a machine can't do resp rates which is important so I believe it's a step backwards to consistently rely on machinery when we're capable of doing it ourselves

[Anna Flaxis, BSN, RN]

So if I took a patients pulse on one wrist and had the oximetry probe on a finger on the same hand but the readings are different I would go with the manual reading. Same goes for BPs and a machine can't do resp rates which is important so I believe it's a step backwards to consistently rely on machinery when we're capable of doing it ourselves

Ours do.

[psu_213, BSN, RN]

Intervention based on vitals is what tells the story of nursing care -- not just the recording of data.

Exactly. It would not matter if I charted a BP of 82/34 and did nothing about it. On the other hand, if this BP was typed out by a printer and then I chart that I started a bolus (increased their pressor dose, etc.) it will be pretty obvious that I saw and acknowledged the VS. If that didn't do it, the RN could initial, time and date next to each VS.

Most of us capture them the monitors and import them into EMR. Some people still type them in by hand but the former approach is (a) much quicker, and (b) eliminates typos.

Obviously the nurse should be looking at them but that doesn't always happen.

[CodeteamB]

Ours do.

Probably not terribly accurately though... We have this function on our monitors, I turn it off on most patients as it will often give me a triple alarm for apnea while the patient is sitting up and talking to me, or patients with rigors, or agitation will register a respiratory rate of 146 or something stupid.

I never rely in this function for my rates, but perhaps yours have a more accurate way of measuring resps than chest wall movement.

I also am loathe to trust abnormal readings from an automatic sphygmomanometer. My first BP and any subsequent abnormal readings are always confirmed with a manual BP. If a patient is consistently very low or high I use manual BPs exclusively.

We are old fashioned, writing down our vitals every time we do them, it takes all of 15 seconds and I'm documenting on the patient anyway so I don't see the big deal, would probably take me longer to print the strip and tape it in the chart. I can see how it would save time if we had computer charting and we could import though.