Should I present vital signs or the physical exam first?

Vital Signs Should Be Presented Before Physical Exam in Clinical Documentation

Vital signs should be presented before the physical examination when documenting patient assessments, as they provide critical baseline parameters that inform the subsequent physical examination and clinical decision-making.

Rationale for Presenting Vital Signs First

Evidence-Based Support

The sequence of documentation follows a logical clinical workflow where vital signs serve as early warning indicators that guide the focus and urgency of the physical examination:

1. Early Recognition of Deterioration: Vital signs are considered the "fifth vital sign" and should be checked by trained staff in all breathless and acutely ill patients 1. They provide immediate information about a patient's physiological status.

2. Triage and Risk Stratification: Vital signs help determine the severity of illness and need for urgent intervention before a detailed physical exam is performed. The Society of Critical Care Medicine emphasizes that vital signs are the most widespread triggers for summoning additional help and evaluation 1.

3. Clinical Decision Support: Abnormal vital signs may direct attention to specific body systems during the physical exam. For example, tachypnea might prompt a more thorough respiratory examination.

Clinical Workflow Considerations

The British Thoracic Society guideline recommends that initial clinical assessment should include vital signs measurement as part of a recognized physiological "track and trigger" system 1. This approach allows clinicians to:

• Quickly identify patients at risk of deterioration
• Establish baseline parameters before detailed examination
• Determine the appropriate level of monitoring and care

Documentation Structure

The recommended sequence for documentation is:

1. Vital Signs (including but not limited to):

   • Blood pressure
   • Heart rate
   • Respiratory rate
   • Temperature
   • Oxygen saturation
   • Pain score (when applicable)

2. Physical Examination (organized by systems):

   • General appearance
   • HEENT (Head, Eyes, Ears, Nose, Throat)
   • Cardiovascular
   • Respiratory
   • Abdominal
   • Neurological
   • Musculoskeletal
   • Skin

Special Clinical Scenarios

Emergency Situations

In critically ill patients, vital signs assessment takes precedence and should be documented first:

• For patients with acute coronary syndromes, the AHA/ACC guidelines emphasize that vital signs should be measured as part of the initial assessment 1.
• In trauma patients, vital signs monitoring should continue during transport and all diagnostic procedures 1.

Post-Procedural Monitoring

After interventional procedures such as endovascular therapy for stroke, the American Heart Association recommends obtaining vital signs first, followed by neurological assessment 1.

Common Pitfalls to Avoid

1. Incomplete vital signs collection: Ensure all relevant vital signs are measured and documented, not just a subset.

2. Delayed recognition of abnormal values: Presenting vital signs first allows for earlier identification of concerning trends.

3. Failure to repeat measurements: Single measurements may not reflect trends. Serial vital signs provide more valuable information than isolated readings.

4. Documentation inconsistency: Using a standardized approach with vital signs first creates consistency across the healthcare team.

By consistently presenting vital signs before the physical examination in clinical documentation, healthcare providers establish a systematic approach that prioritizes early recognition of potentially life-threatening conditions and ensures appropriate clinical decision-making.