Vital Sign Documentation Outline

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VITAL SIGN DOCUMENTATION 5

VitalSign Documentation

Outline

Description of the vital sign documentation process

  • The blood pressure

  • The patients respiration

  • Temperature and pulse

Importance of the vital sign documentation process

  • Helps to identify acute medical problems

  • Quantification of the magnitude of sickness

  • Evaluation of the body’s reaction to physiologic stress

Vital signs documentation errors

  • Misidentification error

  • Multiplication error

  • Transcription errors

Conditions associated with vital signs documentation process

  • Prolonged hospitalization

  • Wrong diagnosis and treatment

  • Death to seriously ill patients

VitalSign Documentation

Theprocess of documenting a patient’s vital signs entails takingmeasurements of the temperature, pulse, blood pressure, andrespiratory rate. Critical symptoms enable the identification ofacute medical problems and the quantification of the magnitude of anillness. They also enable health care practitioners to evaluate howwell the patient’s body copes with physiologic stress sinceprofoundly deranged patients indicate serious sicknesses (DiagnosticErrors, 2016).

Lack of accuracyamong nursing practitioners has the potential to cause identificationerrors. Mistakes occur after the nurses obtain the patients’ nameand goes on to confirm the patient’s wrong identification number.Failure to get the right registration leads to the provision of wronginformation about the sick person (Diagnostic Errors, 2016).

The process isalso susceptible to the multiplication error. It occurs when theclinicians memorize patients’ signs with the aim of recording themlater (Nanjiet al., 2016). Such incidences create room formultiplication since the nurses are bound to forget the initialdetails.

Transcriptionflaws can also occur when the practitioners use scrap papers forinitial data recording with the aim of transferring the informationinto the electronic database. Such incidences increase the chances ofinformation distortion. In addition, the nurses have a highpossibility of providing incorrect patient information (Nanjiet al.,2016).

The inaccuraciescontribute to misleading patient information. It also affects thechoice of treatment plans during admission or during subsequentfollow-ups (Nanjiet al., 2016). Consequently, they lead to adversemeasures that may cause a prolonged hospitalization of the patients.Multiplication errors have the potential of creating the wrongdiagnosis which later transfers to erroneous medication. Incorrecttreatment causes permanent disability. In cases where the patient isextremely sick, transcription errors can contribute to delayedattendance and can lead to fatalities.

References

DiagnosticErrors, (2016). Patientsafety network.Retrieved on 12August 2016 fromhttps://psnet.ahrq.gov/primers/primer/12/diagnostic-errors

Nanji, K.,Patel, A., Shaikh, S., Seger, D., Bates, D. (2016). Evaluation ofperioperative medication errors and adverse drug events. Anesthesiology,124(1), 25-34.

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