Clinical template
Vital Signs Template
Vitals are measurements with a method, a time, and sometimes a reason they were skipped. A blank box next to BP looks the same as 'not needed' and 'machine failed.' Write the number, the units, the route for temperature, the oxygen device, and — when a value is missing — why.
Blank vital signs
Use for clinic intake, triage, or the top of a SOAP/progress note. Repeat any abnormal value and say which reading you are acting on.
Vital signs
Date / time / location (clinic, triage, ward, home): Patient: [initials, age] | Position (sitting / standing / supine): BP (mmHg, arm, cuff size if non-standard): HR (bpm, regular/irregular, pulse vs machine): RR (breaths/min, counted): Temperature (°C, oral / axilla / rectal / tympanic / temporal): SpO2 (%) | oxygen: RA / NP / FM / other | flow: Pain (scale used, location): Weight (kg) | Height (cm) | BMI: Glucose if taken (mmol/L, fasting / random / capillary): Pediatric add: head circumference (cm, if indicated) | length vs height | percentile source if plotted Not obtained (which vital, reason): Repeat readings:
Fictional patients
Examples are made-up. Normal ranges vary by age, pregnancy, and disease. This page does not set your clinic's fever or hypertension protocol. Document what you measured.
What to record every time
Adult ambulatory visits usually need BP, HR, and weight at a minimum when you are managing cardiovascular or metabolic disease. Respiratory complaints need RR and SpO2. Fever history needs a temperature with route. Pain scores belong with the scale you used (0–10 NRS vs FLACC vs something else). Do not write 'vitals normal' without numbers if your note will be the only record of this visit.
| Vital | Adult clinic | Pediatric clinic |
|---|---|---|
| BP | Sit, correct cuff, arm at heart level; repeat if high or if the patient was rushing | Correct cuff; skip only if the child cannot tolerate and the visit does not need it — then say so |
| HR | Pulse or machine; note irregularity | Count if the machine fights movement; include if febrile or cardiac |
| RR | Count; do not copy the oximeter's guessed rate if you did not watch the chest | Count for a full interval in infants; work of breathing is part of the exam, not a vital number |
| Temp | Route matters for comparison | Route matters more; rectal still used in young infants when clinically indicated |
| SpO2 | Room air vs oxygen device | Room air vs oxygen; poor trace is not a number — write poor trace |
| Size | Weight each chronic-disease visit; height when BMI is in play | Weight every visit; length/height; head circumference in infants when you are tracking growth |
When a number is missing
Missing is a decision or a failure. Write which. 'BP deferred — severe pain, recheck after analgesia' is usable. 'BP —' is not. 'SpO2 not obtained, poor perfusion, patient on known home O2 2 L, no new distress' is usable. Leaving pediatric weight blank on an antibiotic-by-weight visit is a medication error waiting for a signature.
- Patient refused — document the refusal and whether you still needed the value for a decision.
- Technique failed (wrong cuff, child moving, oximeter tracing junk) — say failed, not normal.
- Not indicated for this visit (suture removal, results-only) — one line is enough.
- Will obtain later today — then actually obtain it or addendum that you did not.
- Home reading used — label it home, with the device if known, and still record a clinic reading when management depends on it.
Example — clinic set and a skipped value
Family medicine vitals
Adult hypertension follow-up and a toddler with fever, same afternoon. Fictional.
1) 2026-08-26 09:05 clinic. R.K., 59M, sitting, left arm, large cuff. BP 154/92, repeat 148/88 (acting on second). HR 76 regular. RR 16. T not indicated (no fever complaint). SpO2 not obtained (no respiratory complaint). Pain 0. Weight 92.4 kg. Height 178 cm (file). BMI 29.2. 2) 2026-08-26 14:40 clinic. M.T., 22 months. Parent holding. Weight 12.1 kg (naked). Length not repeated today (last month 84 cm). HC not indicated (not a growth-concern visit). T 38.6 axilla. HR 128 (machine, crying; pulse 120 when settled). RR 32 counted. SpO2 99% RA, good trace. BP deferred — uncooperative, no cardiac/renal indication today; recheck if admitted. Pain FLACC 2 (ear pull).
Ward and triage extras
Inpatient notes need a range or a time, not only the 06:00 set: overnight fever, oxygen stepped down, hypotension after a dose. Orthostatic BP is two (or three) labelled readings, not 'positive orthostats' without numbers. For oxygen, the device and flow are part of the vital. For pediatric emergency triage, include work of breathing and behaviour in the exam if they drove acuity — those are not substitutes for RR.
Keep vitals as numbers in the note
Scribeberry can place vitals you dictate into SOAP or progress headings. You still type or import the measurements; do not let a draft invent a blood pressure. Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
Which vital signs should be recorded?
Whatever you used to make a decision, with method and time. Common adult set: BP, HR, RR, temperature, SpO2, pain, weight. Add height/BMI when relevant. Add pediatric length and head circumference when you are tracking growth. Write a reason if a usual vital is missing.
How do pediatric vitals differ from adult?
Expected HR and RR are higher in infants. Cuff size, temperature route, and weight for dosing matter more. Head circumference is an infant/toddler growth measure, not a routine adult vital. A fighting child may need a documented skip rather than a fantasy BP.
Is it acceptable to write 'vitals stable'?
Not as the only record of this encounter if you took numbers. On a ward progress note you can summarize a range ('BP 110–128 systolic overnight') after the values exist on the flowsheet. Clinic notes should carry today's readings.
Will Scribeberry invent vitals from the conversation?
You are responsible for the numbers in the signed note. Dictate the readings or enter them, then generate. If a draft contains a vital nobody measured, delete it before the note enters the EMR.
Templates
