Capturing Manual Vitals (Deep-Dive)

Overview

EPR FireWorks vital signs documentation supports rapid field assessment through main row entry combined with comprehensive clinical context via detail sidebars. This deep-dive guide provides field-by-field documentation procedures for all vital signs components.

Relationship to Vital Signs Hub: This guide provides detailed field documentation. For basic workflow overview and quick reference, see the Vital Signs hub page.

Two-Tier Documentation System:

• Main Row: Rapid entry of critical vital values for immediate trending.

• Detailed Sidebars: Comprehensive clinical context and specialized assessments.

  

Document primary values in main row fields, then access detail sidebars when the clinical situation requires additional documentation context.

All the fields that appear in the main row appear in the detailed sidebars as well, allowing you to complete all fields in a single workflow.

Before You Start

Ensure you have:

• Patient assessment completed and EPR FireWorks ePCR open

• Access to monitoring equipment as available

• Patient consent or implied consent for emergency care

Creating Vital Signs Entry

Create new vital signs entries.

1. Click +.

   

2. The Time sidebar opens automatically. Record vital signs entry time and date:

   1. Select Date and Time

   2. Select YES or NO for Obtained Prior to this Units EMS Care.

      

Documenting Blood Pressure

Recording Primary Blood Pressure Values

Document hemodynamic status. Enter Systolic value in first BP field and Diastolic value in second BP field.

Documenting Blood Pressure Clinical Context

Document comprehensive hemodynamic assessment details.

1. Click the BP section to open the sidebar.

2. Enter Mean Arterial Pressure if measured directly.

3. Select Patient Position (Lying, Sitting, or Standing).

4. Select Method of Blood Pressure Measurement (Arterial Line, Cuff-Automated, Cuff-Manual Auscultated, Cuff-Manual Palpated Only, Doppler, or Venous Line).

5. Select Blood Pressure Qualifier (Left Arm, Right Arm, or Bilateral).

6. Close the sidebar to save changes.

   

Documenting Heart Rate

Recording Primary Heart Rate Value

Document cardiac rate for immediate hemodynamic trending. Enter Heart Rate value in the HR (Cardiac) field.

Documenting Additional Cardiac Assessment Details

Document comprehensive cardiac evaluation including rhythm and ECG interpretation.

1. Click HR (Cardiac) section to open sidebar.

2. Select Method of Heart Rate Measurement, Pulse Rhythm, and ECG Type.

   

3. Select Cardiac Rhythm/Electrocardiography (ECG) interpretation.

4. Select the Method of ECG Interpretations if applicable.

5. Close the sidebar to save changes.

   

Documenting Respiratory Status

Recording Primary Respiratory Values

Document respiratory rate and effort for immediate assessment.

1. In the Respiration section, complete the Respiratory Rate, Pulse Oximetry, and ETCO2 fields

   

2. Click the three-line menu, and then select Respiratory Effort from the sidebar.

   

Documenting Additional Respiratory Assessment Details

Document comprehensive pulmonary evaluation, including oxygenation and ventilation. Complete the empty fields:

1. Click the Respiration section to open the sidebar.

2. Select Pulse Oximetry Qualifier.

3. Select ETCO2 Type (kPa, mmHg, or Percentage).

4. Complete the Carbon Monoxide level if measured.

5. Close the sidebar to save changes.

   

Documenting Neurological Assessment

Recording Neurological Assessment

Document neurological status and responsiveness.

1. Enter Blood Glucose value in BGL field.

   

2. Assess level of responsiveness. Click the AVPU field, and then select the Level of Responsiveness (AVPU) from the sidebar.

   

3. Complete Glasgow Coma Scale (3-15).

Documenting Additional Neurological Assessment Details

Document comprehensive neurological evaluation with clinical context.

1. Click the BGL & AVPU & GCS section to open the sidebar.

2. Measure Glasgow Coma Score. Click the following fields, and then select values from the corresponding sidebars:

   • Glasgow Coma Score-Eye.

   • Glasgow Coma Score-Motor.

   • Glasgow Coma Score-Verbal.

     

Documenting Pain Assessment

Recording Primary Pain Score

Document pain level for pain management protocols. Enter pain score (0-10) in the Pain Scale field.

Documenting Pain Assessment Details

Conduct a comprehensive pain evaluation using standardized scale methodology.

1. Click Pain section to open sidebar.

2. Select Pain Scale Type (FLACC, Wong-Baker (FACES), Numeric (0-10), or OTHER).

3. Verify Pain Scale Score.

   

Documenting Specialized Assessments

Recording Additional Clinical Data

Document specialized clinical assessments in the Other sidebar.

1. Click the Other section to open the sidebar.

2. Document cardiac assessment. Click the Reperfusion Checklist field, and then select applicable contraindications.

3. Calculate trauma severity. Complete Revised Trauma Score. Use the calculator icon to calculate the RTS automatically.

4. Record Temperature. Enter the patient’s Temperature, and then select Temperature Method.

5. For newborn patients, complete the APGAR score. Click the Calculator icon for a detailed calculation.
   Note: See Recording APGAR Score below for the complete procedure.

   

6. For stroke patients: select Stroke Scale Score (Negative/Non-Conclusive/Positive) and Type, and then complete the Stroke Scale Score (Number).

   

Recording APGAR Score

Calculate APGAR score for newborn patient using component-based scoring.

1. In the Other sidebar, click the APGAR calculator icon.

2. Select Criteria according to your findings:

   1. Strength and regularity of heart rate (0-2 points).

   2. Lung maturity (0-2 points).

   3. Muscle tone and movement (0-2 points).

   4. Skin color/oxygenation (0-2 points).

   5. Reflex responses to irritable stimuli (0-2 points).

3. Review the Total Score, and then click Update.