Purpose Statement

To provide comprehensive guidance on completing the Vital Signs section of an electronic Patient Care Record (ePCR) in First Due, ensuring accurate documentation of patient vital signs, lab results, imaging, and medical device events for proper patient care continuity and compliance with NEMSIS standards.

Background Information

The Vital Signs section is the fourth step in the First Due ePCR workflow, designed to follow the natural progression of EMS patient care. This section captures critical physiological measurements and assessments that are essential for patient evaluation, treatment decisions, and regulatory compliance. The Vital Signs section integrates seamlessly with other ePCR components and supports multiple data entry sets for patients requiring ongoing monitoring throughout the incident.

This section is particularly significant for:

• Establishing baseline patient conditions
• Monitoring patient response to treatments
• Meeting NEMSIS data collection requirements
• Supporting clinical decision-making
• Ensuring continuity of care during patient transfers

Required Permissions

Users must have the following permissions to complete the Vital Signs section:

• EMS Documentation Access - Ability to view and edit ePCR forms
• Incident Documentation - Permission to access incident-specific documentation
• Vital Signs Entry - Specific permission to input and modify vital signs data
• Lab/Imaging Documentation - Permission to record lab and imaging results (if applicable)
• Medical Device Documentation - Permission to document medical device events (if applicable)

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Video

Step-by-Step Guide

1. Navigate to Incident Documentation > EMS Incident List.
   
   
   
   
   
   
   
2. Once you have completed the Assessment section of an incident, select the Vital Signs section from the menu of the left side of the ePCR.
   
   
   
   
   
   
   
   

   IMPORTANT: All NEMSIS required fields are notated with an asterisk (*). Depending on your state protocols, additional information could be required.
   
   
   
   
3. The Vital Signs section of Vital Signs allows the user to record all vital signs obtained from the patient. This section includes the following:
   
1. Date/Time* - The date/time vital signs were taken on the patient.
2. PTA - Indicates that the information which is documented was obtained prior to the documenting EMS unit's care.
3. Position - The patient's position while vital signs were obtained. 
   
4. AVPU - The patient's highest level of responsiveness.
5. HR - The patient's heart rate expressed as a number per minute.
6. HR Rhythm - The clinical rhythm of the patient's pulse.
7. HR Method - The method in which the Heart Rate was measured. Values include auscultated, palpated, electronic monitor.
8. SBP - The patient's systolic blood pressure.
9. DBP - The patient's diastolic blood pressure.
10. BP Method - Indication of method of blood pressure measurement.
11. MAP - The patient's mean arterial pressure.
12. RR - The patient's respiratory rate expressed as a number per minute.
13. Respiratory Effort - The patient's respiratory effort.
14. SpO2 - The patient's oxygen saturation.
15. SpCO - The numeric value of the patient's carbon monoxide level measured as a percentage (%) of carboxyhemoglobin
16. ETC02 - The numeric value of the patient's exhaled end tidal carbon dioxide (ETCO2) level.
17. ETCO2 Measure - Indication of method of end tidal carbon dioxide level measurement.
18. Pain - The patient's indication of pain from a scale of 0-10.
19. Pain Scale Type - The type of pain scale used.
20. Temp - The patient's body temperature.
21. Temp Method - The method used to obtain the patient's body temperature.
22. Blood Glucose - The patient's blood glucose level.
23. Cardiac Rhythm - The cardiac rhythm / ECG and other electrocardiography findings of the patient as interpreted by EMS personnel.
24. ECG Type - The type of ECG associated with the cardiac rhythm.
25. Interpretation Method - The method of ECG interpretation.
26. Glasgow Coma Score - Eye - The patient's Glasgow Coma Score Eye opening response.
27. Glasgow Coma Score - Verbal - The patient's Glasgow Coma Score Verbal response.
28. Glasgow Coma Score - Motor - The patient's Glasgow Coma Score Motor response.
29. GCS Qualifier - Documentation of factors which make the GCS score more meaningful.
30. GCS Total - The patient's total Glasgow Coma Score.
31. RTS - The patient's Revised Trauma Score.
32. Stroke Scale Score - The findings or results of the Stroke Scale Type used to assess the patient exhibiting stroke-like symptoms.
33. Stroke Scale Type - The type of stroke scale used.
34. Reperfusion Checklist Result - The results of the patient's Reperfusion Checklist for potential Thrombolysis use.
35. APGAR Score - The patient's total APGAR score (0-10).
    
    
    
    
    
    
4. Once all vital signs are entered, select the  button. To add any additional sets of vital signs, select the  button. 
   
   
   
   
   
   
5. The Lab & Imaging section of Vital Signs gives the user the ability to log Lab or Imaging results. Select the  button to record new Labs or Images. Select the  button when complete. 
   
   
   
   
   
   
   
   
6. The Device section of Vital Signs allows the user to document events performed by a medical device. Select the  button to notate the event. Select the  button when complete.
   
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Best Practices

Data Entry Accuracy

• Double-check all numerical values before saving
• Ensure proper units are selected for each measurement
• Verify timestamp accuracy for multiple vital signs sets

NEMSIS Compliance

• Complete all required fields marked with asterisks (*)
• Follow state-specific protocol requirements for additional mandatory fields
• Maintain consistency in measurement methods throughout the incident

Clinical Documentation

• Record vital signs immediately after obtaining them
• Document any factors affecting vital sign accuracy (patient movement, environmental conditions)
• Use appropriate qualifiers for Glasgow Coma Scale when applicable

Workflow Efficiency

• Complete sections in sequential order for optimal workflow
• Utilize copy/paste functionality for repeated information when appropriate
• Save frequently to prevent data loss

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Troubleshooting & FAQs

Q: What if I need to record vital signs obtained before our unit arrived? A: Check the PTA (Prior to Arrival) box to indicate the information was obtained by another provider or unit.

Q: Can I add multiple sets of vital signs for the same patient? A: Yes, use the Add button after saving the current set to create additional vital signs entries for ongoing monitoring.

Q: What happens if I don't complete required NEMSIS fields? A: The system will prevent submission and highlight missing required fields marked with asterisks (*).

Q: How do I handle abnormal or unobtainable vital signs? A: Use appropriate qualifiers and method selections to indicate circumstances. Document explanations in the narrative section if needed.

Q: Can I edit vital signs after saving? A: Yes, you can return to saved vital signs entries and make corrections before final ePCR submission.

Q: What if the Glasgow Coma Scale total doesn't calculate correctly? A: Verify individual component scores are entered correctly. The system should auto-calculate the total, but manual verification is recommended.

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Related Articles

1. Completing an ePCR - 1. Response
2. Completing an ePCR - 2. Information
3. Completing an ePCR - 3. Assessment
   
4. Completing an ePCR - General Assessment
5. Completing an ePCR - 4. Vital Signs (This Article)
   
6. Completing an ePCR - 5. Treatments
   
7. Completing an ePCR - 6. Billing, Outcomes & External Reporting
   
8. Completing an ePCR - 7. Disposition & EMS Narrative
   
9. Completing an ePCR - 8. Signatures