NHA CCMA: Patient Intake and Vitals

Vital signs

metrics (temperature, pulse, respiration, blood pressure) used to evaluate a patient’s overall health status

Common patient identifiers

name and birth date

Demographics

patient’s name, address, telephone number, insurance information, and emergency contract

Chief complaint

primary reason for the office visit

Subjective

information gathered from what a patient communicates

Medication reconciliation

comparing the patient’s list of medications to the medical record as a safety measure to reduce the risk of improperly prescribing an incorrect or contraindicated prescription (including medication interactions and adverse reactions)

Objective

information that can be observed or measured

Depression

difficulty going to sleep, staying asleep, or getting up in the morning, profound sadness and fatigue, change in appetite, loss of energy

Anxiety

heightened ability to observe or make connections, difficulty focusing on details, sense of panic, irritability, feeling cold, sweaty, heart palpitations, SOB

Blood pressure

force of blood circulating through the arteries

Auscultation

listening with a stethoscope

Systolic

measurement of force while the heart is contracting; top number on a blood pressure reading (phase I)

Diastolic

measurement of force while the heart is relaxing; bottom number on a blood pressure reading (phase V)

Orthostatic hypotension

significant drop in blood pressure during positional changes, particularly when the patient is moving from lying down to sitting or from sitting to standing; also known as postural hypotension

Pulse (heart rate)

number of times the heart beats per minute (evaluated on rate, rhythm or regularity and volume or strength)

Radial pulse

most common site for taking an adult pulse

Brachial pulse

most common site for taking a child's pulse

Respiratory

once complete inhalation and exhalation (evaluated on rate, rhythm, and depth)

Hyperventilation

fast/rapid breathing

Hyperpnea

excessively deep breathing

Dyspnea

difficulty or painful breathing

Orthopnea

difficulty breathing unless in the upright position

Wheezing

whistling sound during breathing

Rales

small clicking, bubbling or rattling sounds

Rhonchi

large airway sounds

Pulse oximetry

percentage of oxygen saturation in the blood

Temperature

relationship between heat production and heat loss in the body

Pyrexia (fever)

temperature greater than 100.4 degrees F

Anthropometric

related to measurement and proportion of the body

Head circumference

not recommended past 36 months

Weight

performed at each office visit (lbs/kg)

Height

performed at each office visit (in/cm)

Body mass index

weight in kg over height in m squared

Normal blood pressure

120/>80 mmHg

Normal pulse

60 to 100 beats per minute

Normal temperature

97.6 to 99.6 degrees F

Normal respiratory rate

12 to 20 breaths per minute