Vital Signs Observations
Time Observations Taken: 08:00
Method & Position: Manual, patient sitting upright.
Temperature Reading: 37.2°C, oral.
Heart Rate (Pulse): 88 bpm, regular.
Respiratory Rate: 16 breaths per minute, normal effort.
Blood Pressure: 130/80 mmHg, sitting, manual.
SpO₂ & Oxygen Use: 98% on room air.
Pain Assessment: 2/10, mild headache.
Impression: Patient appears alert and oriented, no acute distress.
Comparison to Previous Obs: Similar to previous readings.
Escalation & Actions Taken: No escalation required.
Patient Response to Interventions: Patient reports headache improved after taking paracetamol.
Limitations During Observation: None.
Vital Signs Observations
Time Observations Taken: [document when observations were taken] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Method & Position: [note whether observations were taken manually or electronically, and the patient’s position] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Temperature Reading: [document the recorded temperature in Celsius or Fahrenheit and the method used] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Heart Rate (Pulse): [document pulse rate in beats per minute and rhythm if noted (e.g. regular, irregular)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Respiratory Rate: [document number of breaths per minute and note any observed respiratory effort or abnormal pattern] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Blood Pressure: [document systolic and diastolic BP values, patient position if noted, and method of measurement (manual or automated)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
SpO₂ & Oxygen Use: [document oxygen saturation percentage, whether on room air or supplemental oxygen, and delivery method/FiO₂ if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Pain Assessment: [document pain score using a scale or descriptive rating] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Impression: [comment on general patient appearance including pallor, sweating, distress, or other changes from baseline] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Comparison to Previous Obs: [describe any trends or differences compared to prior recordings — improving, worsening, or unchanged] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Escalation & Actions Taken: [document whether abnormal results were escalated to medical team, including time of notification and any response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Patient Response to Interventions:
[note how the patient responded to any interventions initiated due to abnormal observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Limitations During Observation: [record if any issues affected the accuracy or completion of obs — such as agitation, refusal, technical faults, or poor trace] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
(Never come up with your own patient details, observations, or care actions—use only the transcript, contextual notes or care record as a reference. If any information related to a placeholder has not been explicitly mentioned, omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
