18) Recoding Vital Signs Flashcards
1
Q
How can vital signs be recorded?
A
- Graphic flow sheets and/or progress notes
- Electronic medical records (EMR)
- Use institutional procedures for documenting
2
Q
What are benefits of using EMR?
A
- Improved patient safety
- Decreased medication errors
3
Q
Why is timely documentation critical?
A
- Memorizing vitals can create errors
- Compromise data
- Jeopardize patient safety
4
Q
What should be documented besides vital sign values?
A
- Accompanying symptoms (chest pain, dizziness, shortness of breath, etc.)
- Interventions for abnormal values (oxygen, medications, etc.)
5
Q
How are vital signs documented with care maps?
A
- Listed as anticipated outcomes
- Variance notes explain deviations and nursing actions
