Vital Signs

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Trace DC56-10

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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9. Weak vs. strong documentation

Weak — does not survive

Why it fails

Strong — defensible

“Vitals stable. T 98.4, P 74, R 18, BP 124/76.”

Numbers with no parameter, no comparison, no interpretation — a routine task, not skilled observation.

The surveillance model note in §3: the values against the ordered parameters, the trend versus prior, and the reason parameter-based interpretation was required for the diagnosis.

“VSS.”

No values at all; nothing to trend or defend.

Document the actual values against parameters with the interpretation and any action.

“BP 88/50.”

A value with no context, no notification, no action.

The out-of-parameter model note in §4: the value against the notify threshold, the context, the notification, and the monitoring/fall precautions.

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