VITAL SIGN DOCUMENTATION 5
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
Conditions associated with vital signs documentation process
Wrong diagnosis and treatment
Death to seriously ill patients
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.
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.