A complete assessment addresses each of the following each visit, scaled to the patient's diagnosis and stability:
Temperature — value and route (oral, temporal, tympanic, axillary); recognize that route affects the value.
Pulse — rate, rhythm, and quality; auscultate the apical pulse for a full minute when the rhythm is irregular and note any apical–radial deficit.
Respirations — rate counted over a full minute, with pattern and effort.
Blood pressure against the patient-specific ordered parameters, with correct cuff size and technique, and orthostatic measurements when symptoms or fall risk are present.
Oxygen saturation — SpO2 on room air and on oxygen, with the delivery device and flow documented.
Pain as the fifth vital sign — screen each visit; the full assessment lives in the Pain (Core Domain) module.
Weight — measured consistently and trended against baseline and target; volume-status meaning is interpreted in Cardiovascular and the CHF overlay.
The trend across visits — the direction and rate of change, not only the single value.
