This section of the patient chart is used to document the patient's vital signs, physical exams, and, if necessary, wound assessments. This lesson will focus on vital signs and physical exams.
The Vital Signs section displays a list of patient vitals. Abnormal values are highlighted in red.
- A new set of vitals can be recorded by manually entering the data in each field and by clicking Add.
- To remove a record - select the entry and click Remove.
There are a couple of methods for adding exams to the physical exams list.
- Start by clicking New.
- Search for the exam and click Add to add it to the list.
- Click the grid icon to more easily find and add large numbers of exams to the list
- It is now possible to filter by Organ System or Body Part. Select multiple items and Add them to the list. When done, click Save on the next screen, (Add Physical Exams). The selections are now added to the list.
- Values for each exam can be changed by clicking on the corresponding values. Normal values appear in blue, while abnormal appear red.
- An exam marked as "bilateral" can be split into two side-specific exams by clicking either left or right. The exam has now been separated and each side can now be documented independently. All exams allow for Notes (8a) to be added in the right hand column.
- To remove an exam, select the item and click Remove.
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