- Every patient encounter by EMS will be documented. Vital signs are a key component in the evaluation of any patient and a complete set of vital signs is to be documented for any patient who receives some assessment component.
- To insure:
- Evaluation of every patient’s volume and cardiovascular status
- Documentation of a complete set of vital signs
An initial complete set of vital signs includes:
- Pulse rate
- Systolic AND diastolic blood pressure
- Respiratory rate
- Pain / severity (when appropriate to patient complaint)
- GCS for Injured Patients
- When no ALS treatment is provided, palpated blood pressures are acceptable for REPEAT vital signs.
Based on patient condition and complaint, vital signs may also included.
- Pulse Oximetry
- End Tidal CO2
- Breath Sounds
- If the patient refuses this evaluation, the patient’s mental status and the reason for refusal of evaluation must be documented.
- Document situations that preclude the evaluation of a complete set of vital signs.
- Record the time vital signs were obtained.
- Any abnormal vital sign should be repeated and monitored closely.