Version 14.19

Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Well Visits or Encounters > New or Open Note button > Vitals/Growth

Overview

The sections below include steps entering Vitals, other measurements, and Growth Info. Also included below are steps to view Growth Charts and prior Growth Measurements.

Vital Signs: Standard Measurements

1. From an open Well Visit or Encounter note, click Vitals/Growth. The Vital Signs window displays the last saved record.
2. Click the New button. The current date and time are populated. The Date/time monitored field can be changed, if necessary.

1. Enter information in the Standard Measurements by clicking the drop-down or typing in the fields.

1. (Optional) Enter notes in the Comment field regarding the vitals measured.

Vital Signs: Other Measurements (i.e. Pulse Ox, Peak flow, Severity of Pain, etc)

1. Enter information in the Other Measurements by clicking the drop-down or typing in the fields.
2. (Optional) Enter notes in the Comment field regarding the other measurements.

1. To add additional measurements not listed:

1. Click the Add button.
2. Click the drop-down in the Vital Sign field and select from the list.

3. In the Measurement field, click the drop-down and use the number pad or type the measurement.
4. Click into the Norm field and enter a value.
5. Click the Save button.

Growth Measurements

1. Click the Growth Measurements tab.
2. Click the New button. The current date and time are populated. The Measure date field can be changed, if necessary.

1. Enter information in the Measurement fields by clicking the drop-down or typing in the fields. 

1. (Optional) Enter notes in the Comment field regarding the measurements. For example, if your office has different weight scales and you wanted to notate the scale used for a baby's weight check.
2. (Optional) Select the Exclude from growth charts checkbox 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 selecting this checkbox.

View Growth Charts

1. Click the Growth Charts tab.
2. Select a Chart type radio button next to the desired graph on the right side of the window.

View Prior Growth Measurements

1. Click the Growth Measurements tab.
2. (Optional) Growth Measurements can be added from this window by clicking the New button.

Version 14.10

Overview

In this section you will learn how to document Primary and Secondary Vital Signs and Growth Measurements for a patient.

Primary Vitals

1. Click the Vital Signs tab in a well visit note. The Vital Signs window is displayed with the last vital sign entry.

1. Click the Add a new set of vital signs button to add in a new entry. The Date and Time is populated.

1. Click the Fields and enter information.

Note:  Numbers can be entered using numbers on keyboard or by accessing the on-screen keypad by clicking the drop-down menu.

Note:  The default position for BP measurement is sit/stand. To change to Supine, select 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.

1. Type notes in the Comments section regarding the vitals measured, if applicable.

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

1. Click the Secondary Vitals tab.
2. Click the Fields and enter the information.

Note:  Enter Notes in the Comment field. 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.

1. Click 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.

Growth Measurements

1. Click the Green Plus button  in the Growth Measurements tab. The Date and Time are populated 

1. Enter information in each Field. Enter or select from the drop-down menu to enter Growth Measurements.

Enter the measurements in English (inches, pounds) or Metric (cm, kg) units. The system converts for you. For younger children, enter measurement as length or stature. Office Practicum calculates their Growth Percentiles and Body Mass Index (BMI).

1. Enter Notes in the Comment field regarding the measurements. For Example, if your office has different weight scales and you wanted to notate the scale used for a baby's weight check..

Select the Exclude from growth charts checkbox if you do not want to display the measurement when a growth chart is viewed or printed, an example would be sick visits. Always follow the practice policy when selecting this checkbox.

Viewing Growth Charts

1. Click the Growth Charts tab.
2. Select the Chart Type radio button next to the desired graph on the right side of the window.

Note: To print a growth chart, select the Incl Print checkboxes for the graphs you would like to print and click the Printer button. OP displays up to 4 graphs on one page.

Note: Select an option from the Source drop-down menu to view graphs by different sources. 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, there is an option for Premie Corr. on the growth chart. You can switch the view from Preemie to Actual by clicking the Buttons on the Growth Charts tab.

Viewing Prior Growth Measurements

Click the Growth Measurements tab.

Note:  New entries for Growth Measurements can also be added from this window.

Version 14.8

Overview

In this section, you will learn how to document Primary and Secondary Vital Signs and Growth Measurements for a patient.

Primary Vitals

1. Click the Vital Signs tab in a well visit note. The window is displayed with the last vital sign entry.

1. Click the Add a new set of vital signs button to add in a new entry. The Date and Time are populated.

1. Enter information in each Field.

Note:  Numbers can be entered using numbers on keyboard or by accessing the on-screen keypad by clicking the drop-down menu.

Note:  The default position for BP measurement is sit/stand. To change to Supine, select 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.

1. Type notes in the Comments section regarding the vitals measured, if applicable.

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

1. Click the Secondary Vitals tab.
2. Enter Information in each Field.

Note:  Enter Notes in the Comment field. 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.

1. Click the Green Plus button  at the bottom of the Other measurements section to add additional vital signs for: ACR Score, Diffusing capacity of Lung for CO, Pulse Oximetry, RV, TLC or Tanner Stage.

Growth Measurements

1. Click the Green Plus button  in the Growth Measurements tab. The Date and Time are populated.
2. Enter Information in each Field. Enter or select Growth Measurements from the drop-down menu.

Enter the measurements in English (inches, pounds) or Metric (cm, kg) units. The system converts for you. For younger children, enter measurement as length or stature Office Practicum calculates their Growth Percentiles and Body Mass Index (BMI).

1. Enter Notes in the Comment field 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..

Select the Exclude from growth charts checkbox if the measurement should not be displayed when a growth chart is viewed or printed, an example would be sick visits. Always follow the practice policy when selecting this checkbox.

Viewing Growth Charts

1. Click the Growth Charts tab.
2. Select the Chart Type radio button next to the desired graph on the right side of the window.

Note: To print a growth chart, select the Incl Print checkboxes for the graphs you would like to print and click the Printer button. OP prints up to 4 graphs on one page.

Note: Select an option from the Source drop-down menu to view graphs by different sources. 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, there is an option for Premie Corr. on the growth chart. Click the Buttons to switch the view from Preemie to Actual on the Growth Charts tab.

Viewing Prior Growth Measurements

Click the Growth Measurements tab.

Note:  New entries for Growth Measurements can also be added from this window, if needed.