Improving Accuracy and Saving Time: Electronic Vitals Documentation
Vitals signs are perhaps the most fundamental component of patient evaluation. Although there
is overwhelming agreement that vital signs are crucial to both detecting and responding to patient
status, the methods in which vital signs are documented in electronic health records (EHR) has
received limited attention in the research literature. Current practice is to document vital signs on
a piece of paper as they are being taken and then later transcribed to the EHR. This practice utilizes
poor use of clinical time, increases the chance of errors and causes a delay in clinical decision
making possibly leading to escalation of care.
This project intends to use evidence based technology methods to electronically document vital
signs in real time. This method of adopting an informatics based solution in a general medical
surgical unit will demonstrate quality improvement, improved safety and cost containment.