• Kimberly D Johnson, Lindsey Mueller, and Chris Winkelman.
• University of Cincinnati, Cincinnati, OH, USA.
• J Clin Nurs. 2017 Jan 1; 26 (1-2): 148-156.

Aims And ObjectivesTo examine what occurs after a recorded observation of at least one abnormal vital sign in the emergency department. The aims were to determine how often abnormal vital signs were recorded, what interventions were documented, and what factors were associated with documented follow-up for abnormal vital signs.BackgroundMonitoring quality of care, and preventing or intervening before harm occurs to patients are central to nurses' roles. Abnormal vital signs have been associated with poor patient outcomes and require follow-up after the observation of abnormal readings to prevent patient harm related to a deteriorating status. This documentation is important to quality and safety of care.DesignObservational, retrospective chart review.MethodsModified Early Warning Score was calculated for all recorded vital signs for 195 charts. Comparisons were made between groups: (1) no abnormal vital signs, (2) abnormal vital sign present, but normal Modified Early Warning Score and (3) critically abnormal Modified Early Warning Score.ResultsAbout 62·1% of charts had an abnormal vital sign documented. Critically abnormal values were present in 14·9%. No documentation was present in 44·6% of abnormal cases. When interventions were documented, it was usually to notify the physician. The timing within the emergency department visit when the abnormalities were observed and the degree of abnormality had significant relationships to the presence of documentation.ConclusionsIt is doubtful that nurses do not recognise abnormalities because more severely abnormal vital signs were more likely to have documented follow-up. Perhaps the interruptive nature of the emergency department or the prioritised actions of the nurse impacted documentation within this study. Further research is required to determine why follow-up is not being documented.Relevance To Clinical PracticeTo ensure safety and quality of patient care, accurate documentation of responses to abnormal vital signs is required.© 2016 John Wiley & Sons Ltd.

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