Recording and Modifying Vital Signs

  1. Click the Vital Signs button in the top middle of the Exam - Special Tests ExamWRITER chart window.

    The Vital Signs window opens.

  2. Click in the Blood Pressure, Pulse, Height (inches), Weight (pounds), and Temperature boxes.
  3. Click on the blue slider bar to add a measurement to the yellow highlighted text box.

    OR

    Type the appropriate measurement in the yellow highlighted text box.

    You do not need to click on the Systolic, Diastolic, or Pulse text box and then click on the blue slider bar each time that you add measurements to the text boxes. Simply click on the blue slider bar, and your cursor automatically tabs through the yellow highlighted text boxes in the normal prescription writing process and adds measurements to the Systolic, Diastolic, and Pulse text boxes.

    Select one of the following options to autocode the correct PQRS procedure codes in the exam:

    • Select Urgent or Emergent or Patient Refused to autocode the G9745 PQRS procedure code in the exam.
    • Select Active Diagnosis of Hypertension to autocode the G9744 PQRS procedure code in the exam.
    • If abnormal blood pressure readings are documented (>=120 or >=80) and you select Referred to Alternative/Primary Care Provider, the G8950 PQRS procedure code will autocode in the exam. Additionally, the BP measurements and field in the exam will be highlighted red.
    • If abnormal blood pressure readings are documented (>=120 or >=80) and you do not select Referred to Alternative/Primary Care Provider, the G8952 PQRS procedure code will autocode in the exam. Additionally, the BP measurements and field in the exam will be highlighted red.
  4. If you want to add blood pressure and pulse impressions and observations to the EMR, click Observations; otherwise, go to step 6.

    The BP/PULSE Impressions/Observations window opens.

  5. Select the appropriate check boxes, click ADD Item(s), and then click Save/Exit.

    To modify the time, type numbers in the Time text box.

    To add custom text, select the appropriate check box and type text in the Custom text box.

    To clear all items from the Description list, click Clear ALL Items.

    To delete an item from the Description list, select the item and click Delete Item.

  6. Click Save/Exit.

    After you record the patient’s height and weight, the patient’s BMI is automatically calculated.

    To view a graph displaying the patient’s historical vital signs, click the Hx buttons. Click the Copy to clipboard icon to copy the vital signs graph displayed to the clipboard and paste it into another document; click the Print Preview icon to preview the printed version of the graph; and click the Print icon to print the graph.

    To view the patient’s growth charts from ages 2 through 20, click the Growth Chart buttons. Click the Copy to clipboard icon to copy the growth chart graph displayed to the clipboard and paste it into another document; click the Print Preview icon to preview the printed version of the graph; and click the Print icon to print the graph.

  7. Document the patient's temperature as needed:
    1. Click in the Temperature field.

      The Temperature (Fahrenheit) window opens.

    2. Click the slider bar to select the patient's temperature.
    3. Click Save/Exit.
  8. If this is a pediatric patient, document the patient's head circumference as needed:
    1. Click in the Head Circumference field.

      The Head Circumference window opens.

    2. Click the slider bar to select the patient's head circumference in centimeters.
    3. Click Save/Exit.
  9. Click Exit to close the Vital Signs window.