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5.12 – Individual Vital Signs

Monitoring of vital signs is an essential component of caring for all individuals at Open Door in order to:

  • Assess treatment and medication effects
  • Assess current medical condition
  • Early detection or indication of acute issues
  • Identify early signs of clinical deterioration
  • Baseline data for vital tracking for report to treatment professionals

Vital signs include:

  • Respiratory rate
  • Pulse
  • Blood pressure
  • Temperature
  • Level of consciousness
  • Weights
  • Oxygen

A full set of vital signs must be obtained upon admission within first 24 hours.  Vital signs should be completed on-going by assigned nursing personnel (or by delegated DSP staff-Waiver and Johnstown settings) as ordered in individual’s care plan. 

At all times staff should use their judgement regarding the frequency of observations. Under certain conditions, individuals may need continual observation and frequent monitoring of vital signs until they are reviewed and stabilized.

All vital sign observations MUST be charted at the time they are measured.

Vital sign records should be forwarded for review during appointments with physicians. 

Assessment/Observation can include Level of Care.

Last Revised: 8/25/21

Previous 5.11 – Medical Records
Next 5.13 – Laboratory Tests
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