2. Record Vital Signs

This lesson will demonstrate the steps necessary to meet the Meaningful Use Core Measure for recording patient vital signs.

Version:

SOAPware 2011 or later must be used.

Note: To determine the version of SOAPware being used, Click on Help > About SOAPware. This will open a window which will show the version and build of SOAPware currently in use.

Dashboard:

This requirement will be tracked in the MU Patient Dashboard and the Meaningful Use Dashboard.

Measure Criteria

Objective: Record and chart changes in the following vital signs:

  (a) Height

  (b) Weight

  (c) Blood pressure

  (d) Calculate and display body mass index (BMI)

  (e) Plot and display growth charts for children 2-20 years, including BMI

Measure: More than 50 percent of all unique patients age 2 and over seen by the eligible provider should have height, weight, and blood pressure are recorded as structured data.

For more detailed information on this measure, please click on the "Reference" link below. This CMS documentation includes information on exclusions, attestation requirements, a definition of terms and important additional information.

CLICK TO VIEW THE CMS DOCUMENTATION ON THIS MEASURE:

Reference CMS: Record Vital Signs

CMS Stage 1 Changes

Beginning in 2013, CMS had added an optional alternate measure to the objective for Vital Signs.  

Current Measure:  Specifies that vital signs must be recorded for more than 50 percent of all unique patients ages 2 and over.

New Optional Alternate Measure: Amends the age limit to recording blood pressure for patients ages 3 and over and height and weight for patients of all ages.  

The exclusions for this objective have also been changed.  For information on changes to the exclusions, please click the following link: Stage 1 Changes Tipsheet.

At this time, SOAPware continues to calculate this measure based on the "current measure" criteria listed above.  The new alternate measure will be required for all providers in Stage 2 and the changes will be available in an upcoming SOAPware version that is certified to the 2014 Edition of Meaningful Use.

For more information on the Stage 1 changes, please see: Stage 1 Changes Tipsheet.

Measure Calculation

Denominator:  The number of unique patients who are age 2 or older, with at least one face-to-face encounter during the reporting period.

Note: The denominator is unique patients rather than unique patient visits during the reporting period.  Therefore, if a patient is seen three times in the reporting period, you only have to fulfill the rule once for that patient, rather than at all 3 encounters.  However, the patient must have at least one face-to-face encounter during the reporting period in order to fulfill the rule.

Numerator:  The number of patients in the denominator who have at least one entry for height, weight, blood pressure and BMI.

Threshold:  The resulting percentage must be more than 50%.

* Scoring is individual, physician-based and not practice-wide.

Recording Vital Signs in SOAPware

Open the Vital Signs section. If the Vital Signs chart section is not visible, use Chart Navigator to bring it in to view: Chart Navigator.

Vital Signs: Add a Reading Date

To add a reading date:

1. Click the Add Reading Date button

2. A new column will be created with the current date and time displayed at the top

Vital Signs: Recording Height, Weight, Blood Pressure and BMI

Now, vital signs may be entered, including those required for Meaningful Use: height, weight, blood pressure and BMI.

To enter in the vitals, place the cursor in the appropriate box and type the value. The tab key can be used to easily navigate from one box to the next.  The BMI value will be automatically filled in once a height and weight has been recorded for the patient.

Vital Signs: Transfer to SOAPnote

To transfer vital signs to the Objective field of the active SOAPnote:

1. Select a reading date to transfer by clicking on the head of the column.

2. Click the Transfer Vitals Button. The readings for the selected reading date will be transferred to the active SOAPnote.

Note: This step does not have to be completed to meet the Meaningful Use requirements; however, it is recommended by SOAPware to record these vital signs in the corresponding SOAPnote.

Additional Options

The Vital Signs chart section can be customized to include the vitals your practice prefers to record for patients. To learn more about adding to vital signs, see: Vital Signs Section in the  User Manual

Growth Charts

Vital signs must be plotted on a growth chart and displayed for children 2 to 20 years including BMI.

SOAPware contains the following Growth Charts that can be added and displayed for this requirement:

1.  Stature For Age 2 To 20 Years

2.  Weight For Stature 2 To 20 Years

3.  BMI For Age 2 To 20 Years

To learn how to create a growth chart, see Growth Charts in the User Manual

MU Patient Dashboard

This measure is tracked in the MU Patient Dashboard under "Vital Signs".  The Patient Dashboard can be viewed by selecting View > MU Patient Dashboard.

After the patient's blood pressure, height, weight and BMI have been recorded in the patient chart, the MU Patient Dashboard icon will change to a green check mark.  If the patient is under 2 years of age, the Vital Signs icon will display as a green check mark because it is not required to record vital signs information for the patient until they reach 2 years of age and older.

Note: The MU Patient Dashboard will be grayed out if there are no SOAPnote encounters.  It will also remain grayed out if the active SOAPnote encounter is signed off or if the SOAPnote encounter is a Non Face-to-Face encounter.

Meaningful Use Dashboard

This measure is tracked in the Meaningful Use Dashboard under "Vital Signs".  The Meaningful Use Dashboard can be accessed by selecting SOAPware > Meaningful Use Dashboard.

The Meaningful Use Dashboard will display the Numerator, Denominator and percentage for this measure, as well as, graph the Trend for the dates selected.

*Note: The dashboard icon will display a gray X if the threshold for this measure has not been met for the selected reporting period.  The icon will change to a green check mark once the threshold for the meaningful use measure has been met.