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Lesson 6: Recording Vital Signs
6-3
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.
