DOCUMENTATION OF VITAL SIGNS*

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Policy:

Every patient encounter by EMS will be documented. Vital signs are a key component in the evaluation of any patient and a complete set of vital signs is to be documented for any patient who receives some assessment component.

Purpose:

To ensure:

·         Documentation of the evaluation of a patient’s hemodynamic status.

·         Documentation of a complete set of vital signs

Procedure:

1.      An initial complete set of vital signs includes:

• Pulse rate
• Systolic AND diastolic blood pressure
• Respiratory rate
• Pain / severity (when appropriate to patient complaint)

2.      When no ALS treatment is provided, palpated blood pressures are acceptable for repeat vital signs.

3.      Based on patient condition and complaint, vital signs may also include:

·         Pulse Oximetry

·         Temperature

4.      If the patient refuses this evaluation, the patient’s mental status and the reason for refusal of evaluation must be documented. A patient disposition form must also be completed.

5.      Document situations that preclude the evaluation of a complete set of vital signs.

6.      Record the time vital signs were obtained.