Document vital signs with technique, parameter, and interpretation — never as bare numbers:
Temperature, heart rate, respiratory rate, blood pressure, and SpO₂ with the oxygen setting; the technique/route where it matters; and pain as the fifth vital sign.
The ordered parameters (including hold and notify parameters) and the value’s relationship to them and to the resident’s prior values.
The trend across the shift/stay and the clinical interpretation — stable, improving, or an early deteriorating pattern — with the action taken.
MDS-supportive data
Vital-sign findings support the observation-and-assessment basis across the record; pain is coded in MDS Section J, and abnormal trends flow to the relevant clinical item (respiratory, cardiac, infection). The record must show the values, parameters, and interpretation so the skilled observation is supported.
