How to Manually Enter Vital Signs in the Anesthesia Record

Note: This feature is available for practices that have Oral Surgery features enabled.

Vital sign measurements can either be manually added to the Vitals chart in the patient's Anesthesia Record, or a connected monitor can be used. See How to Record a Patient's Vital Signs Using a Connected Monitor for more information.

To manually add vital sign entries in the Anesthesia Record:

1. From the Surgery Vitals tab of the Anesthesia Record, click Time Out.
2. Review the information, and then click Time Out Reviewed.
3. Under Vitals, select Manual to enter the patient's vitals manually.
   
4. For the selected vital sign, enter the numerical value of the measurement.
5. Confirm or enter the time the reading has been taken.
   Note: 
   -- You can manually type a time in the field or use the arrows to change the time by the interval that is saved in the Vitals Options. See Vitals Entry Settings for more information.
   -- When a Start Time is entered in the Anesthesia section (and saved by clicking Update Record), the time for the first set of vitals defaults to this time (e.g., 8:00 AM). If a Start Time is not entered, then the time for the first set of vitals defaults to 12:00 AM.
6. Either press the Enter key on your keyboard or click the Plus sign icon to add the vitals entry to the graphical chart. The color-coded plot point is added to the graph, and the next data type is automatically selected for your value entry. 
   Note: 
   -- Click the icon to reset the time for the entry to the most recent time. 
   -- A warning icon is displayed if there are unsaved vitals (i.e., they have not been added to the event log).
   -- Press the Enter key on your keyboard or click the Plus sign icon to continue adding additional points to the graph during the same session. 
   -- Click Add Entries to Log to add the chart entries to the Event Log and ensure all of the entered data is saved (and maintained on the both the graph and the Event Log entries).
7. Continue entering data through the list, using the time arrows to select the time of each measurement. The graphical chart is updated and plots the points for each vital reading in the designated color. 
   
   Note: 
   -- As you add entries, the plot points advance the line throughout the duration of the surgery. 
   -- Measurements are displayed on the left edge, while time increments (5-minutes) are displayed at the bottom, with 0 being the Start Time of the surgery.
8. Finish filling out the Anesthesia Record, and click Update Record. The information is saved.
   Note: You can return to any of the previous tabs to edit or enter additional information as needed. 
    

Vitals Entry Settings

Click the Settings (cog) icon to select the vitals options.

• Select Cycle Options On Entry to cycle options (Cycle Mode), or de-select it to use Non-Cycle Mode. 
  -- Cycle Mode: Sensei Cloud automatically advances to the next vital sign measurement but maintains the time after adding a reading to the graph (e.g., automatically switches to Diastolic BP after entering a Systolic BP reading).
  -- Non-Cycle Mode: Sensei Cloud retains the current vital sign measurement but automatically advances the time (by the defined interval period) after adding a reading to the graph (e.g., automatically updates time to 11:05am after entering a Systolic BP reading at 11:00am).
• Click the Eye icon next to the option if you want to hide it, and it will be skipped when cycling through the vitals.
• Enter an Entry interval, which is the number of minutes between each entry. This value defaults to five minutes.
• Click the colorful circle next to the vitals option to select a custom color. The selected color is the color of the points and lines that are plotted on the chart for this vital. 
  
  You can click on any color, enter the HEX code, or enter the R, G, and B values, and then click Save. You are returned to the Vitals Entry Settings window, and you must click OK to apply the changes.

Tip: Click the icon for additional helpful information on entering vitals data.

See How to Create an Anesthesia Record for more information.