In this section you will find the steps to document Primary and Secondary Vital Signs and Growth Measurements for a patient.
- Click the Vital Signs tab in a well visit note. The window will automatically open and display the last vital sign entry.
- Click the Add a new set of vital signs button to add in a new entry. The date and time will auto populate.
- Click each field and enter information.
|Note: Numbers can be entered using numbers on keyboard or by accessing the on-screen keypad by clicking the dropdown.|
|Note: The default position for BP measurement is sit/stand. To change to Supine, click the radio button. If multiple entries are done in the same day, Supine and Sit/Stand, an additional entry is required. Prior vital signs are listed in the panel on the right. Select the date to view vital signs taken on that day.|
- Type notes in the Comments section regarding the vitals measured, if applicable.
Secondary Vitals (i.e. Pulse Ox, Peak flow, ACR Score etc)
- Click the Secondary Vitals tab.
- Click in each field to record the information.
|Note: Use the Comment field to write any notes. If secondary vitals were not taken at the original time of the Vital Signs or were retaken click the Green Plus button to add a new entry.|
- Click on the Green Plus button at the bottom of Other measurements to add additional vital signs for: ACR Score, Diffusing capacity of Lung for CO, Pulse Oximetry, RV, TLC or Tanner Stage.
- Click the Green Plus button in the Growth Measurements tab. The date and time will auto populate.
- Click in each field and enter information. Type or click the dropdown to enter growth measurements.
- You can enter the measurements in English (inches, pounds) or Metric (cm, kg) units. The system will automatically convert for you.
- For younger children you will have the option to enter measurement as length or stature
- Office Practicum will calculate their Growth Percentiles as well as Body Mass Index (BMI).
- Type notes in the Comment section regarding the measurements, if applicable. For Example, if your office has different weight scales and you wanted to notate the scale used for a baby's weight check..
- Type notes in the Comment field regarding the measurement if applicable. For example, the office has a different weight scales and you need to notate the scale used for a baby's weight check.
- Click the checkbox for Exclude from growth charts if the measurement is not to show when a growth chart is viewed or printed, an example would be sick visits. Always follow the practice policy when choosing this checkbox.
Viewing Growth Charts
- Click on the Growth Charts tab.
- Click the radio button next to the desired graph on the right side of the window.
|Note: If you are printing a growth chart check mark the boxes of the graphs you would like to print. To Print multiple graphs on one page check mark the desired graphs. OP will put up to 4 graphs on one page. Once all graphs are selected click the printer button.
|Note: You can view graphs by different sources using the drop down arrow in the Source field. Available are CDC 2000, WHO 2007, WHO/CDC or Down Syndrome.|
- If the gestational age entered in the Birth History tab is between 23 and 41 weeks and the child is 36 months or younger you have an option for Premie Corr. on the growth chart. You can switch the view from Preemie to Actual by clicking the button option displayed on the Growth Charts tab.
Viewing Prior Growth Measurements
Click on the Growth Measurements tab.
|Note: New entries for Growth Measurements can also be added from this window, if needed.|