Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician (optional):
Date and Time of Measurement:
Vital Signs
Blood Pressure (BP): Systolic (mmHg) / Diastolic (mmHg)
Heart Rate (HR): Beats per minute (bpm)
Respiratory Rate (RR): Breaths per minute (bpm)
Oxygen Saturation (SpO2): Percentage (%)
Temperature (Temp): Degrees Celsius (°C) or Fahrenheit (°F) (specify which)
Additional Measurements (Optional)
Pain Level (optional): You can use a numeric pain scale (0-10) or a descriptive scale (e.g., no pain, mild pain, moderate pain, severe pain).
Weight (optional): In kilograms (kg) or pounds (lbs) (specify which)
Height (optional): In centimeters (cm) or feet and inches (specify which)
Note:
Depending on your facility and the patient’s condition, you may document additional vital signs like blood sugar levels or urine output.
Always follow your specific protocols for vital signs measurement and documentation.
Additional Considerations:
It’s important to document any abnormal findings or observations related to vital signs. For example, if the blood pressure is elevated, you would note “BP 140/90 mmHg” and may briefly mention if the patient reports any associated symptoms like headache or dizziness.
Vital signs are often documented serially throughout a patient encounter or hospitalization. You can create a table format to track changes in vital signs over time.
This template provides a basic framework for documenting vital signs in a medical record. Remember to adapt it to your specific workflow and institutional guidelines.