OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients.

Version 14.19

This window map article points out some of the important aspects of the window you're working with in OP but is not intended to be instructional. To learn about topics related to using this window, see the Related Articles section at the bottom of this page.

About Patient Encounter: Vital Signs/Growth Measurements

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

The Vital Signs window in an Encounter Note documents the Vital Signs and Growth Measurements for the patient as recorded during their visit. This section of the Encounter Note is chart-driven, meaning that the information populated here is pulled from and pushed back to the same section in the Patient Chart. BP Reference = latest NHLBI guidelines; Other Vital Sign Reference = Harriet Lane.

Patient Encounter: Vital Signs/Growth Measurements Map

Number	Section	Description
1	Vitals/Growth	The Vitals/Growth button accesses the Vital Signs and Growth Measurements window in the patient's Encounter Note.
2	Encounter Function buttons	The Function buttons delete an entire Encounter Note, edit an Encounter Note, or save an Encounter Note.
3	Flag as Incomplete checkbox	The Flag as Incomplete checkbox marks an Encounter as unfinished.
4	Vital Signs and Growth Measurement Tabs	The Enter Vital Signs tab contains fields for entry of the patient's vitals and growth measurements. Vital Signs taken for the current date will be highlighted. The Growth Charts tab maps the results of the patient’s growth include weight, length, height, head circumference, and the calculated BMI graphs. The curves are based on data from the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion, 2000. The Growth Measurements tab displays the current and previous growth measurements. The measurement taken for the current date will be highlighted. These measurements can be excluded from the growth chart by clicking the Exclude checkbox. The Vital Signs Charts tab maps the patient's vitals over time including tanner stage, peak flow, pain severity, respiratory rate, temperature, pulse, pulse oximetry, blood pressure, weight, height, and BMI.
5	Function buttons	The function buttons are used to add a record, edit a record, save a record, cancel a record, and refresh a record.

Version 14.10

About Patient Encounter: Vital Signs Tab

Path: Smart Toolbar > Chart button > Encounters tab > Open Note > Vital Signs tab
Path: Smart Toolbar > Schedule Button > Encounters tab > Edit button > Vital Signs tab

The Patient Encounter helps to code and complete an encounter visit. The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note. The note is added to the patient chart.

The Vital Signs tab documents the Primary and Secondary Vital Signs for the patient as well as the Growth Measurements. The Vital Signs and Growth Chart tabs contain the date/time and result of all vital sign and growth measurements in a patient's chart.

Patient Encounter: Vital Signs Tab Map

Number	Section	Description
1	Encounter Note Editor tabs	The Patient Encounter Note Editor contains the following tabs: Visit Info CC/HPI/ROS Problem List Allergy/Rxn Med Review Immunizations History Risk Assesses Surveys Vital Signs Detail Exam Narr Exam Graphic Couns/CoC Diag Tests Assess/Plan Coding Summary
2	Vital Signs and Growth Measurement Tabs	The Enter Vital Signs tab contains fields for entry of the patient's vitals and growth measurements. The Growth Charts tab maps the results of the patient’s growth include weight, length, height, head circumference, and the calculated BMI graphs. The curves are based on data from the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion, 2000. The Growth Measurements tab displays the current and previous growth measurements. These measurements can be excluded from the growth chart by clicking the Exclude checkbox. The Vital Signs Charts tab maps the patients vitals over time including tanner stage, peak flow, pain severity, respiratory rate, temperature, pulse, pulse oximetry, blood pressure, weight, height, and BMI.
3	Care Plans tab	The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
4	Prior Notes tab	The Prior Notes tab lists the previous encounter notes and messages.
5	Templates tab	The Templates tab lists the templates that are created, edited, and reviewed in the Encounter Templates Editor. Templates are pre-written scenarios you can use in an encounter to document common pediatric diagnoses. Templates include detailed descriptions for the usual pertinent positive and negative findings of a wide variety of illnesses, with a standard assessment, plan and ICD-10 coding. Included with your installation of Office Practicum are Pediatric specific templates.
6	Flag as Incomplete checkbox	The Flag as Incomplete checkbox will mark an encounter as unfinished.
7	Function buttons	The function buttons are used to add a record, edit a record, save a record, cancel a record, and refresh a record.
8	Primary Vitals tab	The Primary Vitals tab fields include blood pressure, pulse, respiratory rate, temperature. Normative values for blood pressure are calculated according to age, sex, and height using reference data from the National Heart, Lung and Blood Institute.
9	Secondary Vitals tab	The Secondary Vitals tab contains pulse oximetry readings, peak flows, pain severity, and other pulmonary function tests.
10	Growth Measurements tab	The Growth Measurements tab contains the date, patient age, stature, weight, BMI, and Comments on measurements.

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