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Patient Care Data Entry: Assessment Page > Vitals Tab

This section documents all vital signs and physiological measurements taken during patient care.

Event Timeline

These date/time fields appear at the top of the tab and show the user these contextually relevant date/time intervals. 

Quick Navigation Buttons

The Vitals Tab features quick navigation buttons at the bottom that allow you to quickly scroll to specific vital sign sections:

  • Heart - Jumps to Heart Rate section
  • Rhythm - Jumps to Cardiac Rhythm section
  • BP - Jumps to Blood Pressure section
  • RR - Jumps to Respiratory section
  • Temp - Jumps to Temperature section
  • GCS - Jumps to Glasgow Coma Score section
  • Pain - Jumps to Pain Scale section
  • Stroke - Jumps to Stroke Scale section

Use these buttons for quick access when documenting or reviewing specific vital signs.

Vital Information

Date - Required (eVitals.01)

  • The date/time when the vital signs were obtained

Prior to EMS Care - Optional (eVitals.02)

  • Indicates whether the vital signs were obtained before this EMS unit's arrival
  • Options: No, Yes
  • Use "Yes" for vitals obtained by other providers or documented from patient records
  • Include vitals from patient records, family reports, or first responders
  • Helps establish baseline and patient trajectory
  • This is the NEMSIS Version 3 method to document prior aid

End Tidal Carbon Dioxide - Optional (eVitals.16)

  • The measured End Tidal CO2 (ETCO2) value
  • Numeric value with decimal precision
  • Range: 0-760.0

End Tidal Carbon Dioxide Type - Optional (eVitals.16 Attribute)

  • The unit of measurement for ETCO2
  • Options:
    • kPa (kilopascals)
    • mmHg (millimeters of mercury)
    • Percentage

Carbon Monoxide - Optional (eVitals.17)

  • The measured carbon monoxide level
  • Expressed as percentage of carboxyhemoglobin
  • Range: 0-99% with one decimal place precision

Blood Glucose Level - Optional (eVitals.18)

  • The patient's blood glucose level in mg/dL
  • Important for diabetic emergencies and altered mental status
  • Can enter "High" or "Low" for out-of-range glucometer readings
  • For glucometers with "High" readings, enter "High" or 600
  • For glucometers with "Low" readings, enter "Low" or 20

APGAR - Optional (eVitals.32)

  • APGAR score for newborn assessment
  • Score range: 0-10
  • Recommended to be taken at 1 minute and 5 minutes after birth
  • Document multiple APGAR scores by creating separate vital sign entries at each time point

Heart

Rate - Optional (eVitals.10)

  • The patient's heart rate in beats per minute
  • Numeric value (0-500 BPM)
  • Note: Pulse Rate and Electronic Monitor Rate have been merged into this single field

Measurement Method - Optional (eVitals.11)

  • The method used to obtain the heart rate
  • Options:
    • Auscultated
    • Doppler
    • Electronic Monitor - Cardiac
    • Electronic Monitor - Pulse Oximeter
    • Electronic Monitor (Other)
    • Palpated

Pulse Rhythm - Optional (eVitals.13)

  • The rhythm pattern of the pulse
  • Options:
    • Irregularly Irregular - Random, unpredictable irregularity
    • Regular - Normal, consistent rhythm
    • Regularly Irregular - Patterned irregularity

Pulse Oximetry - Optional (eVitals.12)

  • Oxygen saturation (SpO2) as a percentage
  • Measured via pulse oximeter
  • Normal range typically 95-100%

Cardiac Rhythm

Rhythm - Optional (eVitals.03)

  • The cardiac rhythm / ECG interpretation by EMS personnel
  • Multiple rhythms can be documented
  • Select the identified rhythm from the extensive list of cardiac rhythms

Type - Optional (eVitals.04)

  • The type of ECG/cardiac monitoring performed
  • Options:
    • 2 Lead ECG (pads or paddles)
    • 3 Lead
    • 4 Lead
    • 5 Lead
    • 12 Lead-Left Sided (Normal)
    • 12 Lead-Right Sided
    • 15 Lead
    • 18 Lead
    • Other

Measurement Method - Optional (eVitals.05)

  • The method used to interpret the cardiac rhythm
  • Options:
    • Computer Interpretation - Automated rhythm interpretation
    • Manual Interpretation - Provider interpretation
    • Transmission with No Interpretation - ECG transmitted without analysis
    • Transmission with Remote Interpretation - ECG transmitted for remote physician interpretation
  • Multiple methods can be selected if applicable

Blood Pressure

Systolic - Optional (eVitals.06)

  • Systolic blood pressure in mmHg
  • The top number in a blood pressure reading
  • Range: 0-500 mmHg
  • Required for ACS Field Triage and patient scoring systems

Diastolic - Optional (eVitals.07)

  • Diastolic blood pressure in mmHg
  • The bottom number in a blood pressure reading
  • Range: 0-500 mmHg

Arterial - Optional (eVitals.09)

  • Mean arterial pressure (MAP) in mmHg
  • Range: 1-500 mmHg
  • Used when arterial line monitoring is in place
  • Can be calculated as: MAP = (SBP + 2×DBP) / 3

Measurement Method - Optional (eVitals.08)

  • The method used to obtain the blood pressure
  • Always document how blood pressure was obtained
  • Different methods may yield different values (e.g., palpated vs. auscultated)
  • Important for trending and quality assurance
  • Options:
    • Arterial Line
    • Cuff-Automated
    • Cuff-Manual Auscultated
    • Cuff-Manual Palpated Only
    • Doppler
    • Venous Line

Respiratory

Respiratory Rate - Optional (eVitals.14)

  • The patient's respiratory rate in breaths per minute
  • Numeric value (0-300 BPM)

Respiratory Effort - Optional (eVitals.15)

  • Assessment of the patient's breathing effort and pattern
  • Options:
    • Apneic - Not breathing
    • Labored - Difficulty breathing, increased work of breathing
    • Mechanically Assisted (BVM, CPAP, etc.) - Assisted ventilation
    • Normal - Regular, unlabored breathing
    • Rapid - Tachypneic
    • Shallow - Reduced tidal volume
    • Weak/Agonal - Inadequate, irregular gasping

Temperature

Temperature - Optional (eVitals.24)

  • The patient's body temperature
  • Can be entered in either Fahrenheit or Celsius
  • System automatically converts and populates the other field when one is entered
  • XML data is sent in Celsius
  • Temperature range: 0-50°C (32-122°F)

Temperature Method - Optional (eVitals.25)

  • The method used to obtain the patient's body temperature
  • Options:
    • Axillary - Underarm measurement
    • Central (Venous or Arterial) - Central line measurement
    • Esophageal - Via esophageal probe
    • Oral - Oral cavity measurement
    • Rectal - Rectal measurement
    • Temporal Artery - Forehead/temporal scanner
    • Tympanic - Ear (tympanic membrane)
    • Urinary Catheter - Via indwelling catheter
    • Skin Probe - Surface skin probe

Glasgow Coma Score

The All Normal button will auto-complete the GCS fields to indicate a total score of 15 (Eye=4, Verbal=5, Motor=6).

Eye - Optional (eVitals.19)

  • Eye opening response component of Glasgow Coma Scale
  • Options (score 1-4):
    • 1: No eye movement when assessed (All Age Groups)
    • 2: Opens Eyes to painful stimulation (All Age Groups)
    • 3: Opens Eyes to verbal stimulation (All Age Groups)
    • 4: Opens Eyes spontaneously (All Age Groups)

Verbal - Optional (eVitals.20)

  • Verbal response component of Glasgow Coma Scale
  • Definitions based on the National Trauma Data Standard (NTDS)
  • Options (score 1-5):
    • 1: No verbal/vocal response (All Age Groups)
    • 2: Incomprehensible sounds (>2 Years); Inconsolable, agitated (<2 Years)
    • 3: Inappropriate words (>2 Years); Inconsistently consolable, moaning (<2 Years)
    • 4: Confused (>2 Years); Cries but is consolable, inappropriate interactions (<2 Years)
    • 5: Oriented (>2 Years); Smiles, oriented to sounds, follows objects, interacts (<2 Years)

Motor - Optional (eVitals.21)

  • Motor response component of Glasgow Coma Scale
  • Definitions based on the National Trauma Data Standard (NTDS)
  • Options (score 1-6):
    • 1: No Motor Response (All Age Groups)
    • 2: Extension to pain (All Age Groups)
    • 3: Flexion to pain (All Age Groups)
    • 4: Withdrawal from pain (All Age Groups)
    • 5: Localizing pain (All Age Groups)
    • 6: Obeys commands (>2 Years); Appropriate response to stimulation (<2 Years)

Coma Score Qualifier - Optional (eVitals.22)

  • Factors that may affect accurate GCS assessment
  • Multiple qualifiers can be selected
  • Options:
    • Eye Obstruction Prevents Eye Assessment
    • Initial GCS has legitimate values without interventions such as intubation and sedation
    • Patient Chemically Paralyzed
    • Patient Chemically Sedated
    • Patient Intubated

Total - Calculated (eVitals.23)

  • Total Glasgow Coma Score
  • Sum of Eye + Verbal + Motor scores
  • Range: 3-15 (3 = worst, 15 = best)
  • Can be manually documented or automatically calculated from eVitals.19 (GCS-Eye), eVitals.20 (GCS-Verbal), and eVitals.21 (GCS-Motor)
  • System automatically calculates when individual components are entered

Revised Trauma Score

Revised Trauma Score - Optional (eVitals.33)

  • Physiological scoring system for trauma patients
  • Calculated from GCS, systolic BP, and respiratory rate
  • Score range: 0-12
  • May be automatically calculated if all components (GCS Total, SBP, RR) are entered

Pain Scale

Score - Optional (eVitals.27)

  • The patient's pain level score
  • Range: 0-10
  • The pain score can be obtained from several pain measurement tools
  • If the pain scale type uses multiple indicators/categories, calculate the total and enter for the pain score

Type - Optional (eVitals.28)

  • The type of pain assessment scale used
  • Options:
    • FLACC (Face, Legs, Activity, Cry, Consolability) - For non-verbal patients
    • Numeric (0-10) - Standard numeric pain scale
    • Other - Alternative pain assessment tool
    • Wong-Baker (FACES) - Pictorial faces scale

Level of Responsiveness

Level of Responsiveness - Optional (eVitals.26)

  • The patient's level of consciousness using AVPU scale
  • Options:
    • Alert - Awake and aware
    • Painful - Responds only to painful stimuli
    • Unresponsive - No response to any stimuli
    • Verbal - Responds to verbal stimuli

Stroke Scale

Type - Optional (eVitals.30)

  • The type of stroke assessment scale used
  • Complete stroke scale for all suspected stroke patients
  • Document time of assessment for accurate stroke alert protocols
  • Options:
    • BEFAST
    • Boston Stroke Scale (BOSS)
    • Cincinnati Prehospital Stroke Scale (CPSS)
    • FAST
    • FAST-ED
    • Los Angeles Motor Score (LAMS)
    • Los Angeles Prehospital Stroke Screen (LAPSS)
    • Massachusetts Stroke Scale (MSS)
    • Melbourne Ambulance Stroke Screen (MASS)
    • Miami Emergency Neurologic Deficit Exam (MEND)
    • NIH Stroke Scale (NIHSS)
    • Ontario Prehospital Stroke Scale (OPSS)
    • Other Stroke Scale Type
    • Rapid Arterial oCclusion Evaluation (RACE)
    • Vision, Aphasia, Neglect (VAN)

Result - Optional (eVitals.29)

  • The overall result of the stroke scale assessment
  • Options:
    • Negative - No stroke indicators
    • Non-Conclusive - Unclear or indeterminate findings
    • Positive - Stroke indicators present

Score - Optional (eVitals.30 attribute)

  • The numeric score from the stroke scale
  • Score interpretation varies by scale type used

Reperfusion Checklist - Optional (eVitals.31)

  • Assessment of contraindications for thrombolytic therapy
  • Previously called "Thrombolytic Screen" in earlier NEMSIS versions
  • Guides transport destination decisions for stroke center selection
  • Critical for determining appropriate receiving facility
  • Options:
    • Definite Contraindications to Thrombolytic Use
    • No Contraindications to Thrombolytic Use
    • Possible Contraindications to Thrombolytic Use
  • Critical for stroke center decision-making

Usage Notes

Multiple Vital Sign Sets:

  • Document vitals at multiple time points throughout patient care
  • Use "Add Vitals" button to create additional vital sign entries
  • Serial vitals help track patient trends and response to treatment

Pediatric Considerations:

  • Glasgow Coma Scale includes age-appropriate descriptors
  • Note differences in verbal and motor scoring for patients under 2 years
  • Use appropriate pain scales (FLACC for non-verbal, Wong-Baker for children)