Thorough Documentation and Handling of Abnormal Vital Signs

I wanted to take a moment to reinforce the importance of thorough and complete nursing documentation, specifically as it relates to vital signs, use of the narrative section of the visit note, and appropriate clinical advisement prior to initiating infusions.

Accurate documentation of vital signs is essential; however, it is equally important to clearly document any patient-reported symptoms or potential contributing factors when vital signs fall outside of normal parameters. This may include information such as pain, recent activity, anxiety, missed medications, illness, or any other factors the patient mentions that could explain the abnormal reading.

The narrative section of the visit note should be used to provide context and explanation for any abnormalities charted. If a patient mentions something that may contribute to an abnormal vital sign, or if a nursing assessment question reveals relevant information, this should be reflected in the narrative portion of the note. This helps tell the full clinical story of the visit and ensures the documentation accurately reflects your assessment, clinical judgment, and any education or guidance provided.

Additionally, when abnormal vital signs are identified, nursing documentation should clearly reflect any nursing interventions performed. This includes reassessment of vital signs, patient education provided, interventions implemented, and any communication with the provider when applicable. While clarification may sometimes be needed verbally after the fact, it is important that all relevant information is documented in the chart at the time of the visit. If we receive a call from a pharmacy or provider with questions regarding abnormal vital signs during and infusion, the visit note should clearly reflect what occurred during the visit so that the clinical picture can be understood without the need for additional follow-up or only minimal follow-up. Clear documentation allows us to confidently address questions based on the charted information.

I also want to emphasize the importance of paying close attention to when abnormal vital signs may require clinical advisement before initiating an infusion. While the standard definition of normal blood pressure is 120/80, we recognize that in the infusion setting many of our patients have a history of hypertension and may routinely run higher despite being on prescribed medications. However, because infusions involve administering additional volume, there is an increased risk of blood pressure trending higher during treatment.

As a general practice, if a patient’s baseline blood pressure is higher than 140s/90s, nurses should reach out to the Agency for clinical advisement prior to starting the infusion to ensure it is appropriate to proceed. This helps prevent situations where medications are prepared, spiked, and/or pooled, only to have to stop or waste medications due to continued elevation in blood pressure. 

While some situations may be outside of our control, careful assessment, appropriate escalation, and thorough documentation help ensure patient safety, support sound clinical decision-making, and provide a clear and accurate record of the care delivered.

Thank you for your continued dedication to our patients and for your attention to these important details. Please reach out if you have any questions or need clarification.

Sincerely, 

Shari Blackmon RN, BSN

Director of Nursing