Purpose

1. To explain how to complete the Vital Signs section of an ePCR.
   
   

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

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Background

The First Due ePCR workflow is designed to follow the following a typical EMS incident:

1. Response
   
2. Information
   
3. Assessment
   
4. Vital Signs
   
5. Treatments
   
6. Billing, Outcomes & External Reporting
   
7. Disposition & EMS Narrative
   

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Video

Directions

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.