You can record a patient's vitals and measurements in their chart without having to start or open an encounter. For example, if you're a nurse or front-end staff member who records a patient's height and weight before a provider sees the patient, you can record these measurements in the Patient Data section of the patient's chart.
When a provider starts an encounter for the patient, as long as the provider has the Examination area set to display historical results, the measurements you entered appear at the top of the Examination area of the encounter.
💡 Tip: If you configured your view of the patient header to include vitals, you can also enter them from there. For more information, see Customizing the patient data header.
Steps
1. Open the patient's chart.
2. Click Start/Open > Patient Data.
💡 Tip: You can also access Patient Data from the Summary view of the patient's chart. However, all vitals may not be displayed, depending on your system setup.
3. Beside Vitals, click Expand.
4. Click any of the vital or measurement names.
The Vitals entry window opens.
5. Beside each of the measurement(s) or vital(s) you want to record, click into the empty field, or list.
6. Type, or select all required values, and click Save. The vitals and measurements are saved to the patient's chart with today's date.
💡 Tip: For quick data entry, you can tab between the different fields.
Updated August 10, 2023