MIME-Version: 1.0 Content-Location: file:///C:/CF22C651/PCP11.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Documentation of Vital Signs

Documentation= of Vital Signs

 

Poli= cy:

 

Every patient encounter by EMS will be documented.  Vital sig= ns are key components in the evaluation of any patient and a complete set of vitals signs should be documented for any patient who receives any assessment comp= onent.

 

Purp= ose:

 

The purpose of this policy is to ensure:

 

  1. Evaluation of every patient’s volume and cardiovascular status
  2. Documentation of a complete set of vital signs

 

Proc= edure:

 

1.   An initial complete set of vi= tal signs includes:

 

      a.   Level of Consciousness

b.   Pulse rate

      c.   Systolic AND diastolic blood pressure

      d.   Respiratory rate

      e.   Skin color and condition=

      f.    Breath sounds (when appropriate to patient complaint)

      g.   Pupils (when appropriate to p= atient complaint)

      h.   Pain severity (when appropria= te to patient complaint) Scale of 1 to 10

 

2.   When no ALS treatment is prov= ided, palpated blood pressures are acceptable for repeat vital signs.=

 

3.   Based on patient condition and complaint, vital signs may include:

 

            a. Pulse oximetry

    =         b. Capnography

    =         c. Temperature

 

4.   &nbs= p;     If the patient refuses this evaluation, the patient’s mental status and reason for refusal of evaluation must be documented.

 

5.   &nbs= p;     Document situations that preclude the evaluation of a complete set of vital signs.

 

= 6.&n= bsp;            = ;      Record the time vital signs were taken.

= 7.&n= bsp;            = ;      Any abnormal vital sign should be repeated and monitored closely.

= 8.&n= bsp;            = ;      Vital Signs shall be obtained no less than every = five minutes for critical patients and every fifteen minutes for stable patients= .

= 9.&n= bsp;            = ;      All patient contacts must include more than one s= et of vital signs unless refusal or multiple PI’s.