Documentation

 

Podcast on documenting vital signs

Vital signs are objective data that provide information about physiological status and responses to stress. Ideally, vital signs are collected before engaging in physical activity, particularly in the deconditioned population. When vital signs are abnormal, the PTA may need to modify treatment approaches or consult with their supervising PT or nursing staff. Documenting vital signs taken throughout the physical therapy session provide evidence of ongoing patient assessment and monitoring.

PTAs make informed decisions when selecting exercises and other interventions by interpreting vital sign measures prior and during treatment. Document findings using consistent terminology and include patient position/situation (lying, sitting, standing) so that the data is transferable and can be interpreted by a multidisciplinary team. Pain documentation may include a rating, location, and other information about its quality and should include its impact on activity and participation. Events or other contextual factors that may contribute to the pain experience are also considered.

:

Vital Sign	Documentation
Heart Rate (HR)	# bpm
Respiratory Rate (RR)	# / min
Blood Pressure (BP)	systolic (mm Hg)/ diastolic (mm Hg)
Temperature (temp)	°C or °F
Oxygen Saturation (O2 sat)	# %

Sample chart note excerpt

S: Pt lying with HOB elevated. Eager to work on getting OOB. Slept better last NOC. Agreeable to in bed exs.

O: Pain 2/10 ache R hip, VS â Rx: BP 146/82, HR 74bpm, RR 14/min, O2 sats 95%

{additional treatment information would follow here, including any additional VS measures collected during the session}

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