Document a patient's vital signs, including height, weight, blood pressure, and pulse.

In the Medical area, click the Vital Signs tab.

The Vital Signs tab only displays when EHR is enabled in Show Features and LOINC codes are downloaded in Importing Code Systems.

Add Vital Sign: Add vital sign entries. See Edit Vital Sign below for details.

Growth Chart: For patients who are 0 - 20 years of age, view a plotted chart of vital sign changes. See EHR Growth Chart.

Vital Signs Grid: A list of vital sign entries, sorted by date.

Edit Vital Sign

Click Add Vital Sign, or double-click an entry to edit. The patient's age determines which information shows in the window.

Enter the vital sign information.

• Date: The date of the entry.
• Systolic/Diastolic BP: Blood pressure measurements. Corresponding LOINC Codes show.
• Height: Patient's height in inches. Height Code is automatically selected when height is entered. Select another option if desired. Required for minor patients when sending prescriptions through Ensora eRx (formerly NewCrop eRx) or DoseSpot eRx.
• Weight: Patient's weight in pounds (lbs). Weight Code is automatically selected when weight is entered. Select another option if desired. Required for minor patients when sending prescriptions through Ensora eRx or DoseSpot eRx.
• BMI: Automatically calculated using height and weight. If BMI is flagged as underweight or overweight, and the patient is older than 18, an Intervention area shows at the bottom of the window. A corresponding LOINC code shows.
• BMI Percentile: Only visible for patients 3 to 16 years of age as of January 1. A corresponding LOINC code shows.
• Pulse: The patient's pulse in beats per minute.
• Notes: Enter any notes pertaining to the patient's vital signs.

If applicable, enter CQM (Clinical Quality Measure) exclusion reasons or interventions.

Exclusion from BMI Exam: This information is included in EHR Clinical Quality Measures exclusions. If BMI height and weight are not recorded due to a patient's condition, select the checkbox that explains the reason.

• Pregnancy: Check this box if patient is/was pregnant during the measurement period. If a default pregnancy code is set in EHR Settings, it displays as the Pregnancy Code and Description. If a default pregnancy code is not set, the Problem List opens to select one. To set a default, click Change Default. Once selected, a diagnosis of pregnancy, using this code, is added to the patient's list of problems with a start date equal to exam date, if an active diagnosis doesn't already exist. Pregnant patients do not count in the denominator of associated CQMs, though do show as an exclusion.
• Other Reason: Check this box if height/weight is not recorded for a reason other than pregnancy. Document the Reason not Performed. If a valid reason is documented, this patient is not calculated in the denominator of associated CQMs.

Interventions and/or Medications: This area only shows in the following circumstances:

• If a patient is 16 years of age or younger as of January 1 of the exam year, and a height and weight is entered.
• If a patient is 18 or older, height and weight are entered, and the calculated BMI is flagged as underweight or overweight.

Interventions

Click Add to document an Intervention.

• Date: Enter the date. The default is today's date.
• Click on an intervention. To filter the list by intervention type, click the Code Set dropdown.
  • Patients 16 or younger: Nutritional Counseling and Physical Activity Counseling interventions are listed.
  • Patients 18 or older: Above/Below Normal Weight referral, medication, or follow up interventions are listed.
• If patient declines the intervention, click Patient Declined.
• Enter a Note (optional).

Select a medication to open the Medication for Patient window. Enter instructions and start date. See Medications.