Table 1.
Data Elements | Attributes or Properties and Values |
Blood pressure |
Body location: right arm, left arm, right leg, left leg, both arms, wrist Method: doppler, manual, auto Position: sitting, standing, lying Device: large cuff, small cuff, thigh cuff, pedi cuff, adult cuff, dinamap As per: home monitoring, from note, doctor repeated, patient reported, nurse verifiedm Patient state: after relaxation, after exam, after medication, orthostatic Comments: e.g. patient did not take medication, second reading |
Pulse |
Body location: radial, apical, brachial, carotid, peripheral, pedal Method: oximeter, EKG, manual Position: standing, sitting, lying Rhythm: regular, irregular, abnormal Abnormal Rhythm: murmur, pre-mature beats, sinus arrhythmia As per: reported by nurse, observed, verified by doctor Negation: no |
Temperature |
Body location: axillary, rectal, per ear Patient condition: eating or drinking (hot or cold), post medication As per: reported by nurse Comments: e.g. patient eating chewing gum |
Respiratory rate |
Rhythm: regular, irregular, deep, rapid, shallow Patient condition: pre and post nebulizar, coughing, respiratory stress, wheezing Patient state: at rest As per: verified by nurse |