Recording Vital Signs: A Neglected Nursing Practice?

Abstract

Bellini Rosa Leda, Damasceno Marilia M, Restituti Ana Carla PL and Machado Mara M

Vital signs are patient’s health status indicators and their measurement and interpretation at opportune moments contribute to the early diagnosis of clinical deterioration and implementation of interventions. The IQG surveyors observed the lack of registration of vital signs during their visits, noting the need to evaluate this practice in IQG’s Health Services Accreditation Programs. The objective of this study is to verify the recording of vital signs in the patient’s chart considering the completeness at the opportune moments. The data was obtained between April 2017 and March 2018 by IQG surveyors during national and international accreditation visits to 141 hospitals participating in Health Services Accreditation Programs. The recording completeness of the eight vital signs (blood pressure, respiratory rate, heart rate, body temperature, pain, pulse oximetry, level of consciousness and urinary output) was checked by hospital. At each visit, between 05 and 07 records of patients admitted to open clinical and surgical care units were randomly examined. In the absence of registration of vital signs in one of the medical records, it was considered that the hospital does not present completeness. Evidence for the recording of vital signs at the appropriate moments (hospitalization, transfer of care, immediate postoperative period, nursing prescription and risk score result) defined the completeness criterion in a sample of 141 hospitals. The data were collected from 141 hospitals. At appropriate times, heart rate and blood pressure was recorded in 96% of hospitals and heart rate, blood pressure and body temperature in 81%. The completeness of vital signs at opportune moments was evidenced in 65% of the hospitals. The next challenge of IQG will be to understand the reasons that lead the nursing team to neglect the measurement, recording and interpretation of vital signs in clinical practice.

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