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 prior to a provider seeing the patient, you can record these measurements in the Patient Data area 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 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 the current value or No Entry.
6. In the entry field, type the value and click Apply or select the checkmark icon.
7. Any vitals that you added or changed appear with the text Updated on the right.
8. When you are done, click Save. The vitals and measurements are saved to the patient's chart with today's date.
Updated March 6, 2022