Vital Signs and Growth Measurements

Version 14.8


In this section you will find the steps to document the Primary and Secondary Vital Signs for the patient as well as the Growth Measurements.

Primary Vitals

  1. Click Vital Signs tab in the Well Visit note.
  • The window will automatically open and display the last vital sign entry.
  1. Click Green Plus button to add in a new entry.

Encounter Note: Vital Signs tab: Enter Vital Signs Window

  1. Click in the field and Enter information.
  • The date and time will auto populate.
Note:  Numbers can be entered using numbers on keyboard or by accessing the on screen keypad by clicking the drop down.
  • For example, entering a temperature reading. Click inside the temperature field. Start typing or click on the 'drop-down' arrow to enter in numbers.

Encounter Note: Vital Signs tab: Entering in Vital Signs

Other Vitals include:

  • Blood Pressure (BP) Sitting/Standing and Supine, Pulse (heart rate), Respiratory Rate and Temperature.
Note:  The default position for BP measurement is sit/stand. To change to Supine, click on the radio dial button.  If entering differing positions, then sit/standing will be one entry. Supine will be another entry for the same day.
  1. Type notes in the Comments section regarding the vitals measured, if applicable.

Encounter Note: Vital Signs tab: Prior Vitals listed on Right side

Prior Vitals are listed on the right hand side. Select the date to view vitals from that day.

Secondary Vitals (i.e. Pulse Ox, Peak flow, ACR Score etc)

  1. Click the Secondary Vitals tab.
  2. Click in the field and Enter information.
Note:  Use the Comment field to write in any notes.

Click the Green Plus button   to add a new entry if the Pulse Ox was not recorded at the original time the Vital Signs were taken.

Note:  For Pulse Ox the "%" sign does not show in this view, but will display on the note summary.
  1. Click on the Green Plus button   at the bottom of the window to add in additional vital measurements such as Pulse Ox, Peak Flow etc.

Encounter Note: Vital Signs tab: Secondary Vitals

Growth Measurements

  1. Click the Green Plus button  in the bottom window.
  • The date will auto populate.
  1. Click in the field and Enter information: Type in or click on drop down to enter Growth Measurements.
  • You can enter the measurements in English (example: 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).

Encounter Note: Vital Signs tab: Growth Measurements

  1. 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, then, the comment field can be used to write this information.

Viewing Growth Charts

  1. Click on the Growth Charts tab in the top window.
  2. Click in the radial dial circle next to the desired graph, on the right hand-side of the window.

 For Example, the below graph is showing the patient's Length. If I wanted to view the graph of Weight gains, I would click on the radial dial circle in front of the 'Weight/Age" option.

Printing Graphs - 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. Then, click on the printer icon.

Encounter Note: Vital Signs tab: Growth Chart

  • View Graphs by Center for Disease Control (CDC), World Health Organization (WHO) guidelines, or combination (WHO/CDC) by clicking on the drop down arrow under 'Source:'. You can also view graphs using the 'Down Syndrome' option. 
  • If the gestational age (must be entered in the Birth History tab) is set to a premature birth, then, you will get an option for 'preemie corr.' on the growth chart. You can switch between the 'Preemie' Correction view and 'Actual' view.

Encounter Note: Vital Signs tab: Preemie Chart

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.

Encounter Note: Vital Signs tab: Growth Measurements Tab