Documentation for Vital Signs
Vital Signs: User Manual
Taking a patient’s vital signs is often seen as simplistic and mundane tasks in comparison with other more complex procedures a medical assistant may perform. This program not only instructs the user in the basic skills needed for taking a patient’s vital signs and measurements, but also offers information as to why the procedure is important to the physician in diagnosing the patient.
This program was carefully designed to assist the user in building the skills necessary for the accurate measuring and recording of patients Vital Signs. Instruction is divided into 6 steps:
Pre-Test: Current knowledge of individual skills is measured through multiple choice questions.
Learn It: The text and pictures take the user step by step through the how’s and why’s of performing each skill.
See It: Each skill is demonstrated through video or narrated animation.
Do It: The user is able to practice the elements of each skill, guided by feedback at every step.
Quiz: Knowledge gained through practice of each skill is tested by multiple choice questions. The score is saved, available for review by the instructor (using the Network Version of the software only), or print for permanent documentation in the user’s file.
Case Studies: The users have an opportunity to use the knowledge gained in the Learn It, See It, Do It and their critical thinking skills in taking a full set of Vital Signs and mensurations on a virtual patient.
It is strongly suggested users start at the beginning, working through the instructional steps of each skill to make the most of their learning experience.
Getting Started
Vital Signs for Medical Assistants is designed for easy use. The Point, Click and Drag system allows you to navigate through the program with ease. Learning is guided with instructional checklists, text and illustrations. Users are encouraged to take advantage of Notes to the User for additional information, resources and references.
Log In
Users will log into the program using first and last names. The program will automatically record user scores in the quizzes so the instructor can track their progress.
Welcome / Introduction Screens
Each screen will have instructional text. Throughout the program, the menu will continue to be available at the top, so navigation between screens is accomplished simply by clicking on any of the menu choices.
Selecting a skill
By rolling the mouse over the menu title Skills, a drop down menu appears. Rolling the mouse down the menu will bring up a submenu for each skill with choices available for Pre-test, Learn It, See It, Do It and Post Test. Roll the mouse over the selected skill and click to bring up the corresponding screen.
Each screen contains instructional text to assist the user in navigation of the program. To move forward to the next screen, select the NEXT button. To review the previous screens, select the PREVIOUS button. For the most effective experience, it is strongly suggested the instructor guide the user through each skill in order, beginning with the Pre Test to measure current knowledge, and then move on to Learn It, See It and Do It prior to attempting the case studies.
Pre-Test
The quizzes are multiple-choice and designed to test the users current knowledge of each individual skill. There will be one question per screen. Answers are selected by clicking on the circle next to the user’s choice, then clicking on NEXT to bring up the next question. When the last question has been answered, a pop up screen will present the score. Clicking on OK to closes the box. The score of this test and that of any previous tests are automatically saved and can be viewed or printed out for the instructor. The details of each score are available by clicking on the link VIEW DETAILS. The scores can be printed for your records by clicking on PRINT. To move on to the next step, roll the mouse over SKILLS to bring up the drop down menu. Follow the menu to the Learn It activity and click.
Learn It
Learn It provides step by step instruction for performing the skill. Throughout the text are italicized terms. Users are encouraged to become familiar with these terms and understand their meanings. It would be helpful to have available a medical dictionary such as the Taber’s Dictionary to assist the users in looking up unfamiliar terms.
An introductory screen offers general information about the skill. Move forward by clicking NEXT. To review a previous screen, select PREVIOUS. When the user has completed the skill, return to the main menu to select the next step.
[pic] [pic]
See It
In See It, the skill is demonstrated so users can hear and see the skill performed. Once they have seen the skill they may select the next step from the main menu. To repeat the demonstration, the user can simply re-select the See It from the main menu.
Do It
The Do It section allows the user to put into practice the knowledge gained from the Learn It and See It. As with Learn It, navigation between screens is accomplished by selecting the NEXT or PREVIOUS buttons.
With each screen, users are instructed to first select [pic] to receive instructions for performing each step. They can check off their progress as each step is completed by clicking on the square next to each step. Feedback is also provided along the way to guide the users’ successful performance of the skill.
Case Studies
The Case Studies offer users an opportunity to use their new skills and to employ a higher level of critical thinking.
Point and click on the Case Studies drop-down menu. Case studies are set up as a day’s list of patients and a summary of their history. Users are asked to take the vital signs and measurements on each of the day’s patients. Each patient has a different history which varies from an annual physical to a patient who has collapsed in the office. Rolling the mouse over the patient highlights the selection. Just click to begin.
• Hints for completing the Case Study exercises
A blank patient chart can be found for each Case Study by clicking on the button at the bottom of the screen:
[pic]
Users are asked to document in the patient’s record, just as in a clinical practice, with the date, patient’s name, age, and chief complaints. After each mensuration is performed, the user will return to this screen and record the results on the patient’s chart.
After reading the patient’s history, the user must select the most appropriate method for taking their vital signs and mensurations by clicking on the link. This will take the user to a virtual examining room where they will begin taking measurements. A negative feedback screen will appear, with an explanation, if they make an incorrect choice Just as in the Do It section, there are CHECKLIST buttons that will provide instructions in navigating the skill.
Once the user has taken the selected measurement, and has returned to record the findings on the patient’s chart, they may choose another vital sign or mensurations. Once all measurements are completed and recorded, the user may select another patient by selecting Case Studies from the main menu.
General Information
Four recurrent themes are reinforced throughout every skill:
• Patient identification
• Infection control
• Consent
• Charting of results
The importance of identifying the patient is emphasized with every skill throughout the program and in accompanying Notes to the User. Many offices, in the spirit of HIPAA regulations, now call patients from the reception room using only the patient’s first or last name. Users are instructed to ask the patient to repeat their name and/or the birth date to confirm the identity of the patient and to counter check the patient name and birth date with the chart.
The most common transmission of infectious pathogens from host to recipient is through unwashed hands. Hand washing prior to contact with a patient is emphasized with every skill. There are additional ways of creating barriers to the transmission of infectious pathogens is also discussed throughout the program.
Implied consent is given when a patient willingly cooperates with a procedure. The instructional text reminds users of the need to communicate clearly with the patient about what procedure will be performed and to offer patients the opportunity to ask questions. It is emphasized that a patient may feel more willing to cooperate and give consent when a procedure is explained to them.
The patient chart is a legal record of tests, exams, treatments, and patient contacts. Simply said, “If it is not in the chart, it didn’t happen”. Recording results, and recording them correctly, is reinforced in multiple ways throughout the program. Users are shown correct charting in Learn It and See It, and asked to record results with each completed skill in Do It. The Case Studies ask them to record results on a virtual chart.
Resources
Resources for additional study and information are listed in the User Notes and in the Instructor Notes. With each skill, specific references are listed so the user can easily find more information about that particular skill. At the end of the Instructor notes, there is a list of resources used in the development of this program.
Users are asked to keep in mind that, in real-life experience, every medical office has its own procedures for taking a patient’s vital signs and mensurations which may differ slightly from what is found in this program. Equipment may be different, methods may not be exactly as seen here, or the preferences of recording the results may vary. Users are reminded that it is normal and to be expected. The goal of this program is to give a basic understanding of how to take a patient’s vital signs and measurements. Future clinical experiences will shape and fine-tune the medical assistant’s skills.
• Helpful References, available from Thomson Delmar Learning
Body Structures & Functions, Tenth Edition by Ann Scott and Elizabeth Fong
Clinical Handbook for the Medical Office, Second Edition by Heller & Krebs
Comprehensive Medical Assisting: Administrative and Clinical Competencies, Third Edition by Lindh, Pooler, Tamparo, Dahl
Fundamentals of Anatomy and Physiology, Second Edition by Donald C. Rizzo
Medical Assisting: Administrative and Clinical Competencies, Fifth Edition by Keir, Wise, Krebs
Medical Terminology for Health Professions, Fifth Edition by Ann Ehrlich
Tips for using Vital Signs
Adult Height and Weight
Height (or stature) is generally measured when measuring a patient’s weight. The most common scale is that of a balancing scale with a measuring bar as shown here. Though digital scales are available, it is important for the user to know how the basic balancing scale works.
Ask the user to start with the Pre-Test to evaluate their current knowledge of the skill. Once they have completed the three steps of Learn It, See It and Do It, taking the Post-Test will evaluate the user’s progress.
• Hints for completing the Adult Height and Weight Do It exercises
You will note for measuring Height and Weight, we have chosen a female figure in the Patient Instruction screen, which is consistent throughout the Do It, and Case Studies section. The instructions are nonetheless universal in that the patient, male or female, should set aside anything they may be carrying which may affect the weight reading, and remove anything which may affect the height reading.
Instruct users to use the decimal system when entering their measurements in the answer box.
Example: instead of 6 ½, type 6.5.
When weighing the patient, there is a window above the top of the balance bar which enlarges the top bar numbers, making it easier to read when moving the larger weight.
Infant Weight
In a clinical setting, the user will encounter many types of infant scales: scoop digital, digital scales built into the examining table and the scoop scale balance bar. This program will teach the basic scoop scale with balance bar.
The differences in weighing an adult and an infant are emphasized to the user. Obviously, an infant is weighed either sitting or laying down on the scoop scale. The scale is also prepared differently. An infant scale is balanced before and after placing the barrier towel on the scale. In Notes to the User, users are given information regarding the different ways in which a child may be prepared for weight measurement. For example, some offices or clinics may ask the parent to provide a clean dry diaper to be placed on the scale when balancing. Then the parent may re-diaper the baby before placing him or her onto the scoop base. Other offices will ask the baby to be completely undressed and balance the scale with only a utility towel. Though either is correct, for this learning program we have chosen the latter.
It would be helpful to have available examples of the various charts used in pediatric practice for recording a child’s growth. Although information about charting a child’s growth on a chart is included, at this time, actual practice marking the growth chart is not available within the program
• Hints for completing the Infant Weight Do It exercises
To balance the scale, the user must click on the balance bar. A pop up window allows them to click on the screw at the far left of the balance bar to balance the weights, or, to use “click and drag” to move the weights until the scale is balanced when weighing the baby.
Click and drag is used to move the baby and towel to the scale.
The user must perform the steps in the correct order. If a mistake is made, a pop up window will offer feedback to guide them in the correct direction.
If this, or any, skill was difficult for a user, at the end they will find a [pic] button. This will take them back to the beginning to practice again.
Infant Length & Head Circumference
Length (or stature), and head circumference are important measurements in observing the growth patterns of an infant. Measurements outside the normal range may be indications of illness or disorders.
There are different ways to measure a child’s length. There are 2 ways discussed in this program, marking the table paper at head and heel, then measuring the distance between marks and using the measuring strip at the back edge of the examining table. Alternate methods are described in Notes to the User, such as some pediatric examining table papers have hash marks in quarter inches printed on the paper, therefore a measuring tape is not required. The Do It practice uses the measuring strip at the back of the table edge.
It would be helpful to have available examples of the various charts used in pediatric practice for recording a child’s growth. Although information about charting a child’s growth on a chart is included, at this time, actual practice marking the growth chart is not available within the program.
• Hints for completing the Infant Length & Head Circumference Do It exercises
Infant Length: Preparing the patient
Ask the user to look at the picture. The user may check off those instructions he or she feels would be necessary to weigh an infant.
Infant Length & Head Circumference: Entering measurements
Remind the user to record the results using the decimal system, then to click on [pic] Feedback will guide them through the skill.
Example: instead of 6 ½, type 6.5.
Temperature
Users will learn four methods to measure temperature: Oral, axillary, rectal, and aural (tympanic). The thermometers that will be taught in this program include electronic, self-contained digital, disposable Tempa-dot, and aural (tympanic). Mercury thermometers are being phased out due to the dangers of breakage and mercury exposure, therefore these thermometers will not be taught in this program, nor will be the type of thermometer that is held against the skin.
Users are again reminded the equipment encountered in clinical practice may vary in appearance or ease of use. This program will teach the basics of how to use each method. In actual practice users will easily adapt to any differences in equipment.
Oral Temperature (Disposable Thermometer)
Disposable thermometers, although not quite as accurate as other methods, are convenient for taking a patient’s temperature in most circumstances. They are available for both oral and rectal use. An advantage of using disposable thermometers is that any possibility of cross contamination between patients is eliminated. They do have to be placed properly and do require timing for accuracy. In Do It exercises, the user will have the opportunity to time both the measurement, and the stabilizing times when using a disposable TempaDot thermometer.
• Hints for completing the Oral Temperature (Disposable Thermometer) Do It exercises
An oral temperature will be measured with the disposable thermometer in this program. Users are asked to choose necessary supplies, correctly place the thermometer, and time the measurement precisely to obtain an accurate reading.
Disposing of the thermometer is most correct in a biohazard container as the thermometer is contaminated with bodily fluids. Not all offices do for disposable thermometers, but for this program, biohazard containers are the correct answer.
Oral Temperature (Electronic Thermometer)
Users will practice measuring an oral temperature with an electronic thermometer. The design of the equipment may differ but they all function very similar. Electronic thermometers are accurate, easy to use, and measure the temperature in about 15 seconds. Electronic thermometers are portable, can run on rechargeable batteries, or remain plugged into an outlet. Electronic thermometers are equipped with a timer which signals when the maximum temperature is reached. It will turn off automatically if not used in a pre-set time frame. Probe covers are stored in the unit for convenience and the color-coded probes are easily changed for taking oral or rectal temperatures. The probes are designed so the medical assistant’s hand touches only the probe collar and not the actual probe. When the measurement is completed, the probe cover is easily ejected into the proper container.
• Hints for completing the Oral Temperature (Electronic Thermometer) Do It exercises
Users are asked to choose the proper supplies, select the proper color probe, use a probe cover for safety, and position the probe tip properly to obtain the desired reading. When the signal is heard, they must read the measurement and enter the answer in the box.
In order to [pic], the user must click on the probe to remove it from the patient’s mouth. As in the previous discussion about disposable thermometers, disposal of the probe cover into the biohazard container is correct.
Axillary and Rectal Temperature
Self-contained digital thermometers are popular in clinical practice. They are small, convenient and easy to use. They vary slightly in style but all run on battery, show the reading in an LCD window, have memory of the last temperature taken and take approximately 60 seconds to read the temperature. Though probe covers for digital thermometers have a paper strip that is peeled back when the thermometer is slipped into the cover, in this program, for simplicity, it is sufficient for the user only to select a probe cover for use prior to measuring the patient’s temperature.
Users will practice measuring an axillary and rectal temperature using a digital thermometer. The Learn It sections describe instances when it is, and is not, appropriate to take an axillary or rectal temperature.
• Hints for completing the Axillary Temperature Do It exercises
When preparing the patient for taking an axillary reading, the user must first use click and drag to prepare the axilla with a towel, if done properly, a pop up window with feedback will instruct them to either close or next. They must select close to place the thermometer.
When clicking on the thermometer, the towel will disappear and the user will be able to drag the thermometer to the axilla. The feedback window will guide the next step.
Before entering the rectal or axillary reading, the thermometer must be removed from the patient’s axilla or rectum.
• Hints for completing the Rectal Temperature Do It exercises
The user must first select the proper supplies for taking an infant’s rectal temperature. Clicking [pic] takes allows them to select the correct picture for positioning of patient and thermometer. The child’s buttocks must be spread, the thermometer must be on, and inserted to the correct depth.
When the signal is heard, the user must click on the thermometer to remove it from the rectum, type the reading in the answer box then click [pic]to receive feedback.
Aural Temperature
The hypothalamus maintains homeostasis or the body’s status quo, which includes temperature. The hypothalamus and the tympanic membrane share the same blood supply Therefore, when done correctly, an aural, or tympanic, measurement is the most accurate representation of the patient’s temperature. An aural thermometer is very convenient as it is not affected by food or drink temperature, access is usually available, and within 2 seconds, you have a reading. The disadvantage is that if there is excessive cerumen or the probe tip is not pointing at the tympanic membrane, the temperature measurement will be inaccurate. Users will learn when it is, and is not; appropriate to take a pt’s temperature, as well as the importance of proper tip angle.
• Hints for completing the Aural Temperature Do It exercises
The tip must be removed from the patient’s ear before clicking [pic] If the user receives an incorrect answer feedback, they may have chosen an incorrect thermometer position in the previous screen, and must go back to re-select the correct positioning.
Pulse
Users will learn to take a radial, apical and carotid pulse and the reasoning for each. The user will need to asses the patient and the situation to decide the correct pulse point to use. Users will also be instructed in the proper recording of results for the different pulse points. Also discussed, though not in detail, are the TPR ratio and pulse deficit. The instructor may need to provide further information in that regard.
Radial Pulse
Users are instructed when it is appropriate to measure the radial pulse and where to find the pulse point. The program allows the user to measure the pulse for 15, 30 or 60 seconds, just as they will find in clinical practice. An allowance of plus or minus 2 beats is made for the correct answer.
• Hints for completing the Radial Pulse Do It exercises
As it is impossible to actually feel a pulse in a computer program, the pulsations are simulated with a visible artery pulsing in the patient’s wrist. It is a bit more difficult, and takes a little practice, to watch the pulsing and the timing of the pulse than it is to actually measure the pulse in a real clinical situation. It may require a bit more practice on the user’s part to count the pulse in this manner. An extra session allowing the users to find each other’s pulse, or even their own, will allow the users to experience the variations in volume and rhythm while measuring a patient’s pulse.
Apical Pulse
An apical pulse is generally measured in adults when the radial pulse is irregular, or in patients with known cardiovascular disease or in patients who are taking cardiac medications. This may be an excellent time to teach more in depth about a pulse deficit.
Users are instructed to find the apical pulse point by palpating the ribs or by approximating the position by placing the medical assistant’s hand on the chest. The pulse point can be approximated using either hand. Both are correct. The right hand is chosen for this learning program.
In a baby, obviously, the medical assistant’s hand is far too large to use in approximating the apical pulse point. The pulse is heard just below the left nipple.
Carotid Pulse
In an emergency, the carotid artery is the best site to assess the patient’s pulse. It is usually only counted for 15 seconds checking quickly for rate or irregularities.
• Hints for completing the Carotid Pulse Do It exercises
Again, as it is impossible to actually feel a pulse in a computer program, the pulsations are simulated with a visible artery pulsing in the patient’s neck. It is a bit more difficult, and takes a little practice, to watch the pulsing and the timing of the pulse than it is to actually measure the pulse in a real clinical situation. It may require a bit more practice on the user’s part to count the pulse in this manner. An extra session allowing the users to find each other’s pulse, or even their own, will allow the users to experience the variations in volume and rhythm while measuring a patient’s carotid pulse.
Respirations
Respirations are normally measured when the patient is unaware that his or her breathing is being observed. Users are instructed that although they practice it as a separate skill in this program, in clinical practice, they will count the pulse for 30 seconds and count respirations for the following 30 seconds. A tip for remembering the pulse while counting respirations is given for counting both vital signs, which can be reinforced while users are practicing on each other.
Blood Pressure
When measuring blood pressure, users are taught to measure the palpatory systolic pressure prior to the auscultory pressure. The palpated systolic pressure can be measured either at the radial artery or at the brachial artery pulse point. Both are correct and both methods are shown. For simplicity and continuity, the user will practice taking the palpated systolic pressure at the brachial artery site, since they will need to know the location of the brachial pulse point for placement of the diaphragm when taking the auscultory blood pressure.
• Hints for completing the Blood Pressure Do It exercises
When taking the palpated systolic pressure, the pulse will be simulated by a beating heart. Again, it is a bit more difficult having to watch both the beating heart and the pressure gauge than in clinical practice where the brachial pulse is felt while watching the gauge. Individuals normally will see and hear just slightly different, therefore it is acceptable to obtain a reading within a range of plus or minus 2 mm of Hg.
When taking the auscultory pressure, the pulse is audible. Again, as individuals hear and see at a slightly different rate, the same range of plus or minus two is allowed for the correct answer.
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