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Lesson 6: Recording Vital Signs
6-2
6-2. HOW IS A DA FORM 3950 COMPLETED?
If you are taking vital signs on a ward, you will probably enter your readings on the DA Form 3950. The form provides room to record the vital signs for several patients over an extended period (normally one day).
a.
Identification Information. The name of the patient’s are entered in the first column on the right. The time (approximate military time) that you are taking the vital signs is entered in the heading of the next column. Normally, vital signs are taken every 4 hours (6 times a day).b. Vital Signs Information.
(1) The patient's temperature. The patient’s temperature, pulse rate, and breathing (respiration) rate are entered in that order. The sets of numbers are normally separated by a hyphen to make reading easier. Temperature readings with tenths are normally written with the tenths raised (for example, 986). The degree symbol and Fahrenheit or Celsius symbol are not written in order to save space. For example, figure 6-5 shows that Mr. Jones’ vital signs at 1400 were:
(a) Temperature: 100.0º F.
(b) Pulse rate: 86 beats per minute.
(c) Breathing rate: 19 breaths per minute.
Figure 6-5. Example of a DA Form 3950, Flowsheet for Vital Signs and Other Parameters, with vital signs entries.
(2) Blood pressure. When a patient’s blood pressure is taken, it is recorded in the same block as the TPR readings, but above those readings. The systolic-slash-diastolic form is used. The abbreviation "mm Hg" is not entered in order to save space. At 1600, Mr. Jones’ vital signs were taken again. This time, his blood pressure was also taken. His blood pressure readings were:
(a) Systolic: 136 mm Hg.
(b) Diastolic: 90 mm Hg.
c. General Rules. The readings recorded on the DA Form 3950 conform to general rules given previously in this subcourse. These rules are summarized below.
(1) All Fahrenheit temperatures are to be rounded to the nearest two-tenths of a degree.
(2) All Celsius temperatures are to be rounded to the nearest one-tenth of a degree.
(3) All rectal temperatures are to have a circled "R " above the temperature reading.
(4) All axillary temperatures are to have a circled " A " above the temperature reading.
(5) All temperatures without a special symbol are understood to be oral temperatures.
(6) All pulse rates are to be recorded in even whole numbers.
(7) All blood pressure readings are to be recorded in even whole numbers. The systolic (highest) pressure is entered in front of the diastolic (lowest) pressure. The systolic and diastolic readings are separated by a slash (diagonal line), such as "130/96."
(8) All breathing rates are recorded as whole numbers. The numbers may be either even or odd.
6-3. HOW IS VITAL SIGNS INFORMATION OBTAINED FROM A SF 511?
Specific instructions for entering information on a SF 511, Vital Signs Record, are not given in this subcourse. However, the instructions given below should be sufficient for you to read vital sign information from the form.
a. Patient Identification. The "Patient Identification" section at the bottom gives the patient’s name, social security number, hospital (register) number, ward to which the patient is assigned, and other information.
b. Heading.
(1) Month-Year/Day. The third line gives the calendar day. The calendar month and year are on the fourth line under "Month-Year."
(2) Hospital Day. The first line tells how many days the patient has been in the hospital. The day that the patient enters the hospital is "hospital day 1."
(3) Post-Day. This line tells how many days it has been since the patient’s surgery or since the patient delivered (gave the birth). This line is left blank if it does not apply. For example, "DOS" (day of surgery) is entered on the date that the surgery occurred. The number "1" entered in the next day’s column. A "DOD" entry means "day of delivery" (day that the patient gave birth).
(4) Hour. The fourth line is used to record the hours at which the patient’s vital signs are taken (not when they are actually recorded on the form).
(a) The graphic section of the form is broken into seven major sets of columns. Each set is used to record the vital signs for a single day.
(b) Each of the seven major columns is divided into two of columns. The first set is used for recording the vital signs taken in the a.m.; the second set is for recording the vital signs taken in the p.m.
(c) Each of the two columns is divided into three columns by dotted lines. Each dotted line column contains a single set of vital signs. This allows six sets of vital signs (one set every four hours) to be recorded each day.
(d) The time that the vital signs are taken is recorded at the top of the column on the fourth line. Civilian time is used. This means that vital signs taken at 0200, 0600, 1000, 1400, 1800, and 2200 (a typical schedule) would have column headings of "2," "6," "10," "2," "6," and "10" respectively.
c. Vital Signs.
(1) Pulse. The pulse is graphed as an open or empty circle (o). It is read using the "Pulse" column on the left of the form. Each solid horizontal line denotes 10 beats per minute. There are four dots between each pair of horizontal lines. Each dot adds two beats per minute to the line below. For example, the patient’s pulse rate at 1000 on 15 December 1985 as shown in figure 6-2 is 76. On the SF 511, the pulse rate symbols are connected by straight lines.
NOTE: Solid lines are not drawn through the symbol since that could make the pulse
temperature symbol look like a temperature symbol.
(2) Blood pressure. Blood pressure readings are graphed as crossed lines (X). The point that the lines cross indicates the blood pressure reading. There are two X’s in each hour column for each blood pressure reading. The higher "X" is the systolic; the lower is the diastolic. They are read using the "Pulse" column. Each solid horizontal line denotes a change of 10 mm Hg and each dot between the solid lines denotes a change of 2 mm Hg. For example, the blood pressure reading for 1000, 15 December, on figure 6-2 is 120/84. The systolic and diastolic readings are connected by a straight line. The systolic reading is not connected to other systolic readings and the diastolic reading is not connected to other diastolic readings. The blood pressure readings may also be written in the "Blood Pressure" section below the graph.
(3) Temperature. The temperature symbol is a large dot or filled circle (●). It is read using the "Temperature" column to the right of the "Pulse" column. Each solid horizontal line denotes a change of 1o F. Each dot represents an additional 0.2o F. For each example, the temperature (oral) reading shown for 1000, 15 December, on figure 6-2 is 100.2o F. Like the pulse symbol, temperature symbols are connected one to another by solid lines.
NOTE: A solid horizontal line is drawn in at the normal (98.6 o F) level to aid in your
graphing efforts.
(4) Breathing. Breathing rates are not graphed. Instead, the breathing rate is written in at the bottom of the graph column on the "Respiration Record" line.
d. Other Entries. The blocks below the "Blood Pressure" section are used as specified by the local SOP. Normally, the top line is used to document weight changes. The rest of the section is usually used to document patient fluid intake and output.
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