What should you document when taking vital signs?

• A. Record only the date and time.
• B. Record estimated values.
• C. Record exact values, date/time, and any abnormal findings; report to the nurse.
• D. Do not document vitals to protect privacy.

Answer: (C)

The main idea is to record vital signs accurately and communicate any abnormal findings to the nurse. You should document the exact measurements, include the date and time of the measurement, and note any readings that are outside normal or baseline ranges. This creates a precise, timely record that the care team can use to track trends and decide on interventions. Simply recording only the date and time, or guessing values, doesn’t provide useful information and can lead to unsafe decisions. Not documenting vitals to protect privacy isn’t appropriate; privacy is about confidentiality, while accurate documentation is essential for quality care. For example, if a temp is 101.2°F, blood pressure is 150/92, pulse 110, and respirations 22 at 10:15 a.m., you’d record all exact values with the time and note any abnormal findings, then report them to the nurse.