| Entering Vitals Data

This chapter an overview of the process of viewing and entering vitals for patients using the vxVitals module. The following topics and sections covered in this chapter are listed below:

u Searching for single and multiple patients

u Entering Vitals data

u Editing a user template

u Viewing allergies

u Viewing Growth Chart information

u Marking Vitals as entered in error

Searching for a Single Patient

vxVitals provides multiple methods to search for a patient from the main menu screen. Searching for a patient requires that the Patient Selector Panel must be opened. Opening the Patient Selector Panel can be done using one of two methods:

u Method 1: Click the View drop-down menu, then select Pt Select.

View Menu ...Pt Select

u Method 2: Click the Pt Select button on the Header Bar.

Header Bar...Pt Select

u The last lookup that was used appears when opening the Patient Selector.

Patients Group List

Patients Group List

A patient can be searched for by using the Patients Groups List under the header bar which contains the Unit, Ward, Team, Clinic, and All buttons.

u Unit allows the user to select a patient from a list of Nursing units.

u Ward allows a user to select a patient from a list of MAS Wards.

u Team allows a user to select a patient from a list of teams defined in the OE/RR List file.

u Clinic allows a user to select from a list of clinics for a predetermined period of time (e.g., Today, Yesterday, Past week).

u All allows a user to select a single patient by name or SSN.

To begin searching for a patient names

1. Click the desired Patient Groups List button,

2. Enter the patient's name, or the last four digits of the patient's Social Security number in the Patient Name (Last Name, First Name or SSN#) field.

a. A list of patients, matching the search criteria entered, will be displayed on the bottom left portion of the Patient Selector screen.

3. Double-click the desired patient name from the results listed.

Patient Name (Last Name, First Name....)

Entering Vitals Windows and Functions

When a patient is selected from the patient's results list, the Confirm Patient Selection screen appears.

Confirm Patient Selection

The Confirm Patient Selection screen displays additional information such as the patient name, sex, date of birth, ward location and room-bed to confirm the correct patient has been selected to view. If the patient selected has a sensitive record, a sensitive patient screen will be displayed. This is to ensure the patient's information is available on a need-to-know basis only.

Confirm the correct patient has been selected by reviewing the patient name, sex, and date of birth and then click the OK button. If the information is not correct, click the Cancel button and search for the appropriate patient again.

The patient vitals information will appear in the vxVitals Data Vitals Area window (Figure 18).

The Data Vitals Area window contains several sections allowing access to view, enter and modify information for the selection patient(s). This displays existing vitals data on the top half of the screen in graphical format and in a spreadsheet-like data grid on the bottom half.

The patient selector panel can be toggled off and on to expand the data vials area as seen below.

**The data grid information can also be viewed as text by using the Data Grid Report from the Reports drop down menu.

Data Vitals Area

Data Vitals Window Components

The Vital Data window displays a visual representation of the patient data that can be viewed based on a selected time frame. Vitals are displayed with the earliest data on the left to the most recent information on the right of the graph.

To expand the graph and grid displays for a selected patient, click the Pt Select button to open and close the Patient Selector panel.

Graphical Display Window Components

Date Range Selection: Allows patient data to be viewed within a selected date range. Predetermined date ranges are available as listed below:

u TODAY: Represents the current date. The current date can also be represented by the letter T.

u T-1 thru T-30 date ranges: these date ranges display data based the current date minus the number of days prior. For example T-7 indicates 7 days worth of data from the current date, or one week prior to the current date.

u Six months: Displays six months worth of vitals information.

u One year: Displays one year worth of vitals information.

u Two years: Displays two years worth of vitals information..

u All results: Displays all available vitals data for the selected patient.

u DATE RANGE: Displays all available vitals between a specific designate range that is not listed in the above predetermined date ranges. Clicking DATE RANGE button will display the start and stop dates that can be selected to view vitals in this date range.

Graphical Display: Displays vitals in a graphical format with the earliest data on the left to the most recent information on the right of the graph.

Time Scale: Used as a sliding scale located between the graphical and data grid vitals areas. Used to slide display vitals along a time frame when slid either left to right.

Graph Options: Four check boxes for Values, Time Scale, 3D and Allow Zoom displays can be selected to toggled off and on with the graphical window. This area can be minimized by right-clicking in the Graph Options area and selecting Show/Hide Graph Options from the pop-up menu. This menu option may also be selected from the View drop-down menu.

Graph Option checkbox description:

u Values: Displays numeric labels for each point on the graph.

u Time Scale: Displays the graph in actual time instead of evenly distributed intervals. The data points in the graph can also display additional information about the entered vitals when clicked.

u 3D: Creates a 3D effect on the graph. This option is only available when the Time Scale checkbox has been checked.

u Allow Zoom: Displays the graphical zoom options. This area provides multiple zoom options listed below:

-- The Zoom in (+) and Zoom out (-) buttons can be clicked to zoom in and out of the Graph In button.

-- A selection box can dragged around one or more data values to view in detail.

-- A new value in the Zoom Percent text box can be manually entered to change the zoom percentage. The Reset Zoom button will reset the Zoom Percent box to its original value.

Two additional graph options can be accessed from this window by right-clicking in the Graph Options menu.

u Select Graph Color: provides the different background colors.

u Print Graph: provides printing option to send the graph display to a printer. The graph will be printed as it appears on the screen at the time of printing.

These options are also available under the File drop down menu.

u Vitals Drop Down Menu Selection: (Note you will see no name beside this drop-down window).
This is located at the bottom left of the Graph Display window it Provides a drop down list of the available vitals that will display in the vitals graphical display window.

u Graphical Data Grid: Displays specific vitals by selecting the desired vital row heading in the data grid below the graphical window. The Pulse graph is selected in the example above.

Single Patient View

When a single patient is selected, the Enter Vitals button in the header bar is enabled.

| Enter Vitals can also be selected under the File drop-down menu.

If a patient's location is not assigned, the Enter Vitals button will display the Hospital Location Selector window when selected.

Hospital Location Selector Window

To select a location, select the appropriate Appointments, Admission or Name tab from the top of Hospital Location Selector screen. The description of each tab is detailed below:

u The Appointments tab lists all appointments for this patient within the last year.

1. Select an appointment to that clinic location.

2. Click the Select button.

u The Admissions tab lists all existing admissions for this patient.

1. Select the appropriate admission.

2. Click the Select button.

u The Name tab allows the hospital location to be searched by name.

1. Enter the name of the hospital location.

2. Select the hospital location from the list that displays.

3. Click the Select button.

If a location has already been assigned to a patient the Hospital Location Selector window will not open and the Enter Vitals screen appears.

The Enter Vitals screen allows the user to enter vitals and measurements that have been added to a Template that they have access to. These vitals will be visible in the vxVitals component as well as in the vxVitals data window on the vxCPRS Cover Sheet if applicable. Whichever template that the user had selected previously will remain upon successive log-ins until the user changes the template in vxVitals (the process of changing templates is illustrated in the Expanded View button description).

| Note: A template is a set of assigned vitals values and measurements that define which vitals display on the Vitals Entry screen. In the example below, there are 13 particular vitals (beginning with Temperature and ending with Estimated Delivery Date) that have been added to this template. Additionally, templates also determine which qualifiers are associated with each vital. Individual Templates are created in the vxVitalsManager application by a user with access to the GMV MANAGER Key. A complete and detailed description of vxVitals Templates is available in the vxVitalsManager Manual.

Enter Vitals

The Vitals Entry screen contains multiple components that allow for vitals and measurements to be entered for a patient.

Enter Vitals screen header bar: Similar to the header bar from the initial login screen, the Enter Vitals screen also contains a header bar. The header bar contains patient demographic information, patient location and time of the current user log-in session, as well as provides clickable buttons from which to perform associated functions.

Date/Time button: This button allows the user to specify the date and time in which the vitals were recorded. If the user enters vitals and saves that entry without clicking this button, vxVitals will automatically associate the current date and time upon saving the new entry.

Enter Vitals Date/Time Screen

The default date is set to the current date and time. The current date can also be selected by using the Today button. A future date cannot be used when selecting the date and time.

If the date for the vital measurement is different than the current date, follow the steps listed below: measurement is different than the current date, follow the steps listed below:

1. Click the desired date from the calendar.

2. Select a time the measurement was taken using one of the following methods.

u Enter in the time in the Time field.

u Select the time using the hour and minute lists under the Time field.

u Click the Now button to select the current time.

u Click the Midnight button to select 12:00 midnight.

3. Click the OK button to complete the selection, or click the Cancel button to cancel the selection.

Hospital button: Within the header bar, there is a section that details the current patient location. However, if the patient had vitals recorded while on a different ward/unit or while at a different facility, the Hospital button allows the user to change the location of where the vitals were recorded to provide further accuracy in the patient record. Once clicked, the Hospital Locater Selector screen will open and a user may select a previous admission time or an Outpatient Appointment time to associate with a set of recorded vitals. Once selected, simply click the Select box to finish the association.

Hospital Location Selector

Exp. View button: The Expanded View button allows a user to select from any additional Vitals templates that may have been created and assigned to a user. Once selected, this button opens the screen to also show a series of available templates grouped by System, Division, Location, and User. Select the desired template to populate a different set of vitals to enter for the selected patient. A user has the ability to click the plus or minus signs in the expanded section to show more or less of a template grouping. With a desired template highlighted, simply click Save and Exit. This template will now be defaulted upon successive logins.

Expanded View

| Note: vxVitals templates are created and managed in the vxVitalsManager application. For further instruction, please review the vxVitalsmanager section of this manual or contact your local facility system application coordinator.

Latest V. button: This button brings a text view of the latest vitals entries for the patient. Each recorded vital and all associated qualifiers will be displayed. Additionally, the date and time of each entry as well as the name of the person recording the information will also display.

Latest Vital Entries

The Enter Vitals window in vxVitals enters vitals into the fields available based on the selected (or defaulted) template. vxVitals allows appropriate vitals values to be entered as well as choosing associated qualifiers. Additionally, appropriate units may be determined to measure the recorded values and document if a patient was unavailable for vitals collection or refused to have a particular or all of their vitals recorded.

Once a template is selected or defaulted, a template summary appears directly below the Header Bar on the Enter Vitals screen. Directly under the template summary, the following check boxes appear:

Template Summary below Header Bar

The Enter Vitals window provides checkboxes to document patient availability and refusal based on vitals collections. The available checkboxes to use during documentation are listed below.

u Patient on pass: Vitals could not be recorded due to the patient being away from the facility. The Patient on Pass check box is locate to the left side of the figure above. Hovering the mouse of the check box displays the following pop up Mark all vitals in the template as ‘Patient on pass’.

u Enable U and Enable R: Enable or disable the selection of the corresponding boxes in any of the rows of vitals.

u Units as Drop Down List: Displays a drop down list allowing for changes to the measured units in the Units column. For example, a patient's temperature may be recorded in Fahrenheit or in Celsius.

The Vitals template contains the following columns for each vitals that can be entered:

u U… Unavailable checkbox that records if the vitals cannot be taken. The text for this checkbox may be very small with only the U displaying.

u R…Refused checkbox that records if the patient refused to have the vital taken. The text for this checkbox may be very small with only the R displaying.

u Vitals shows vital or measurement name.

u Value field is where the user enters the numeric value.

u Units displays which unit of measurement has been selected or defaulted to quantify the entered value.

-- Users may be able to change a particular unit of measurement, however some units may be defaulted at a system level by a system’s administrator within the vxVitals Manager application

u Qualifiers show a drop-down arrow that will bring up a small window with the defined qualifiers for that vital or measurement. If a default qualifier has been defined, it will display to the right of the button. If the user changes the qualifiers, the text to the right of the button changes (see Qualifier section below).

Vitals Template

Qualifiers- Additionally, vxVitals allows a user to choose from drop-down menus to make changes to any value Qualifier. Each vital has a pre-determined set of qualifiers from which to choose and a user needs to simply click the appropriate Qualifier drop-down box to select the appropriate qualifier.

| Note: Just as vxVitals Templates are created in vxVitalsManager, Qualifiers are chosen in the same manner. Qualifiers may be set to default for certain values based upon decisions made by local system administrators.

In the example shown below, the value for a patients Pulse has been entered. By clicking on the Qualifier drop-down box, a user can select each of the Qualifier variables listed and click OK when finished.

Pulse Qualifiers Example

Entering numeric measurements for vitals are completed by typing the values in the appropriate vitals fields. The defaulted qualifiers for each vital appear to the right of the down arrow button.
The drop-down-arrow button next to each vital may be used to select a different qualifier, if necessary.

Vitals Screen Showing Default Qualifiers

Once all vitals have been entered, the appropriate saving options will need to be selected to save the entered information. The different saving options are listed below:

u The Save button will save the data for the entered vitals.

u The Save And Exit button will save the data and close the Enter Vitals window.

u The Exit button closes the Enter Vitals window without saving any data.

| Note the Latest V. button from the Header Bar will display all newly added vitals on the bottom of the screen. The latest Vitals displays the most recent reading for each vital on record for the patient. If there is no reading for a particular vital (e.g., CVP), then that vital is not listed.

Latest Vital Entered Shown on Bottom

How to enter Vitals for a Single Patient Summary:

1. Click the Enter Vitals button from the header of the selected patient.

2. Click the Date/Time button to set to when the vital measurement(s) was recorded.

3. Select the appropriate template from the Templates list, if necessary.

4. Enter the measured vitals values into the appropriate vitals fields.

u If necessary, change the units for the vital.

u If necessary, select the appropriate unavailable check boxes for vitals that cannot be measured.

5. Select the appropriate save options button to save the date for these entered vitals.

6. Review the newly entered vitals in the latest vitals pane.

Multiple Patients View

vxVitals allows vitals to be entered for multiple patients in a single session. This can be useful when vitals are taken for a group of patients in one ward or a unit at one time. Entering vitals for multiple patient is the same as entering vitals for a single patient in the following areas:

u Selecting the Date/Time of a measured vital

u Assigning patient Hospital Location when necessary

u Entering vitals for vitals for selected patients

Selecting multiple patients from a list requires that the appropriate patient group is displayed to chose from. Patient Groups can be displayed by clicking the Unit, Ward, Team, Clinic or All buttons from the Patient Selector Panel. With all the patient names displayed, multiple patients can be selected by holding down the Ctrl key and clicking the desired patient names. Holding down the Shift key and dragging across patient names will select a range of patients. When all desired patient names are selected, then click Input Vitals for the Selected Patients button at the bottom left corner of the screen may be utilized.

Input Vitals for Selected Patients

No patient confirmation screen will appear when multiple patients are selected. If any of the selected patients contain a sensitive record, a sensitive record confirmation screen will appear for the patients. This confirmation screen will contain a screen prompt(s) to move forward to the Enter Vitals window.

If any of patient's locations are not assigned, the Input Vitals for the Selected Patients button will display the Hospital Location Selector window when selected.

Hospital Location Selector Window

To select a location, select the appropriate Appointments, Admission or Name tab from the top of Hospital Location Selector screen. The description of each tab is detailed below:

u The Appointments tab lists all appointments for this patient within the last year.

1. Select an appointment to that clinic location.

2. Click the Select button.

u The Admissions tab lists all existing admissions for this patient.

1. Select the appropriate admission.

2. Click the Select button.

u The Name tab allows the hospital location to be searched by name.

1. Enter the name of the hospital location.

2. Select the hospital location from the list that displays.

3. Click the Select button.

If a location has already been assigned to a patient the Hospital Location Selector window will not open and the Vitals Entry screen will then display.

The Vitals Entry screen for multiple patients window opens with the selected patients displayed in Patient List above the Templates list.

Patient List Location

To view the Patients List, ensure the Exp View button from the header bar is clicked to display the expanded view of the Vitals Entry Form. The selected patient from this list will have an arrow to the left of the name in the Patients List.

Patient List Expanded

Templates: Displays a list of all available vitals templates for the selected patient from the patient list. Vitals templates define which vital measurements can be displayed on the Vitals Entry screen. Select the appropriate template for the selected patient by clicking on the correct template name.

Templates

Entering Values

Enter all appropriate vitals and measurements for the selected patient vitals. With all vitals entered, the information must be saved to the selected patient using the Save button on the lower right side of the screen.

Vitals Screen Showing Entry Fields

Once saved, another patient from the patient list (see figure below) can be selected to enter the next set of vitals. Selected patients with new vitals saved will display a check with a yellow circle next to their names in the Patient list. With the new vitals added to the selected patient, the next patient in the list is ready for their set of vitals to be added.

Patient List Showing Patients with Added Vitals

Vitals for each patient will appear at the bottom of the screen in the Latest vitals for this patient: display section of the screen. The Latest V. button from the header bar can be used to view or hide the latest Vitals display on the bottom of the screen. The latest Vitals displays the most recent reading for each vital on record for the patient. If there is no reading for a vital (e.g., CVP), then that vital is not listed.

If all vitals are entered for all patients, exiting the enter vitals area can be done by clicking the Exit button.

How to enter vitals for Multiple Patients summary

1. Click the Enter Vitals button from the header of the selected patient

2. Click the Date/Time button to set to when the vital measurement(s) was recorded.

3. Select the appropriate template from the Templates list if necessary.

4. Enter the measured vitals values into the appropriate vitals fields.

u If necessary, change the units for the vital.

u If necessary, select the appropriate unavailable check boxes for vitals that cannot be measured.

5. Select the appropriate save options button to save the date for these entered vitals.

6. Review the newly entered vitals in the latest vitals pane.

Marking Vitals as Entered in Error

Incorrect vitals cannot be deleted in vxVitals. If vitals are entered and saved incorrectly, they must be marked as Entered in Error. Once marked, the vitals can be changed with the correct vital information. The incorrect vitals will no longer display in the data grid and graph, but will continue to be stored in the vxVitals database. Marking a vital as entered in error requires a patient be selected in the main Vitals window. The incorrect value's date column heading must be clicked to display the Entered in Error screen.

Entered in Error Screen

The Entered in Error screen displays all vitals entered on the selected date and who entered the vital. When the incorrect vital is selected, the reasons for entering the vital in error become available to choose in the Reason: section. The reasons for entering a vital in error are listed below:

u Incorrect Date/Time

u Incorrect Patient

u Incorrect Reading

u Invalid Record

Once the correct reason is selected, the Mark as Entered in Error button becomes available. Once clicked, the Confirm confirmation screen will appear. From the confirmation screen, click the Yes button to confirm the entry has been marked in error. Click the No button to select a different entry.

Confirm Confirmation

With the incorrect vital marked as entered in error, the correct vital may now be entered for the selected patient.

If more than one vital has been entered in error on the same date, multiple vitals may be selected by holding the Ctrl key and clicking multiple vitals on the Entered in Error screen.

Entered in Error Window

Other options for accessing the Entered in Error screen to mark a vital as entered in error include the following methods:

Method 1:

1. Right-click in the data grid.

2. Select Entered in Error.

Right-click Menu Showing Entered in Error Selection

Method 2:

1. Click the File menu.

2. Select Entered in Error.

Entered in Error Selection from File Menu

To mark a vital Entered in Error Summary:

1. Open a single patient and review vitals.

2. Locate the incorrect vital.

3. Click the column heading.

4. Select the incorrect vital from the Entered in Error screen.

5. Click the appropriate Reason.

6. Click the Mark as entered in Error button.

7. Click the Yes button to confirm the vital as entered in error or the No button to cancel.

8. Enter the new correct vital and save.

To print a list of all Entered In Error Vitals for this patient, see the Printing a Report section.

Creating a User Template

Templates are a set of vitals and measurements grouped together to make data entry simpler and easier. Templates provide a way for a user to customize specific sets of vitals/measurements to fit the needs of individual or groups of users. Templates are created in vxVitals Manager based on the needs of a user, facility or facility location by the system administrator.

Users may create their own templates if the Allow User Templates system parameter is enabled in vxVitals Manager. Users may only see their own created Templates and are unable to see templates created by other users. If the Allow User Templates parameter is not enabled, a user is unable to create their own templates.

To create/edit a template for a system, division, or location, refer to the Creating/Editing a Template section in Using vxVitals Manager section of this manual.

To create a new template for user level, click File from the menu bar of the vxVitals main menu and select Edit User Templates.

Edit User Template Menu Selection

The Create/Edit user Templates screen allows a specific template to be created and customized based on a User's specific needs. Once created, specific vitals can be added or removed from a user template based on a user's preference. To begin creating a template, click the New Template button.

Create/Edit User Templates

The Create New Template screen appears:

Create New Template

Enter a name for the new template in the Template Name: field. The name should distinguish the values or purpose that this specific template represents. The Template Name: field has a maximum length of 30 characters. Once the template name is entered, click the OK button to continue.

The new Template now appears on the Create/Edit templates window under the User Templates panel. This panel displays all user created templates from a user. When selected from this list, the new template information will display in the Vitals Template Editor section of the window.

The selected template name will appear under the Template Name: field. A description of the template can be entered in the Description: field. Entering a description is optional and the field has a maximum limit of 50 characters.

Create/Edit User Templates Screen

The selected template can now be edited by adding vitals and qualifiers. Click the plus sign button (+) on the right side of the screen to add the appropriate vitals to the template.

Vitals Template Editor

The Add Vital window displays. This window contains a list of all available vitals in the program. Select all appropriate vitals by holding the CTRL key and clicking all desired vitals to add. Alternatively, holding the Shift key and dragging the cursor along the list will select a range of vitals. Once all vitals are selected, click the OK button.

Add Vital Window

The Vitals Template Editor screen now displays the selected vitals in the Template Vitals field. The appropriate qualifiers settings can be added or edited to a selected vital at this time. Click on a vital to display the available qualifiers associated to it. These qualifiers appear on the bottom portion of the screen.

Vitals Template Editor

Choose the vital qualifier by clicking the desired checkbox that displays under the Quality field. Only one qualifier may be selected from this list. If applicable, select the appropriate measurement scale by clicking either the US or Metric radio buttons located on the right hand corner of this screen.

| Note: Each Vital will have it's own set of specific qualifiers to customize. Ensure all appropriate Qualifier check boxes are filled when adding vitals.

To remove a vital from a template, select the vital and click the minus sign (-) button on the right side of the Vitals Template Editor screen. Use the up/down arrow buttons to move vital around on the list. A US or Metric system of measurement for each qualifier may also be selected by clicking the appropriate US or Metric radio button.

Template Vitals

When all of the new Template's appropriate fields are entered, vitals added, and qualifiers included, save the new template to the User Templates list by clicking the save Save button at the bottom right side of the screen.

Save Template

Editing User Templates

User Templates can be edited from the Create/Edit Templates screen. Once the desired Template is selected from the User Template field, it may be edited or modified to change the Template name or description. Additionally, a user may add or Delete vitals and/or modify any qualifiers.

Once all Template edits are finished, confirm the changes by clicking the Save button at the bottom right side of the window. The template is ready to use.

Deleting a User Template

To delete an existing User Template, select the template name in the User Templates List to select it, then click the Delete button at the bottom of the window.

Delete User Template

When all new Users Templates are added, edited and/or deleted, click the Close button at the bottom of the window to return to the main Vitals window.