Measure Components	The CDU uses a standard process/protocol for properly measuring BP consistently and correctly, including:
	• Adoption and implementation of a protocol for accurate measurement and documentation of BP.
	• Availability of staff who are trained in measurement and documentation of BP.
	• Documentation of staff assessment of correct BP measurement skill.
Elements	Protocol includes preassessment tools, checklists, and metrics to assess gaps in care.
	Certification of staff in correct BP measurement skills.
Recommended Protocol	2017 Hypertension Clinical Practice Guidelines.4
	Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research.133
Documentation	Documenting the implementing protocols may impose additional burdens on HCOs. Potential options to consider:
	• Attestation, self-reported information
	• External auditor/rater
	• Competency testing
Rationale
Accurate measurement and recording of BP are essential to categorize level of BP, ascertain BP-related ASCVD risk, and guide management of high BP. Office BP measurement is often unstandardized, despite the well-known consequences of inaccurate measurement. Errors are common and can result in a misleading estimation of an individual’s true level of BP if staff are not trained and a protocol is not followed. The use of automated office BP measurements should be considered as part of the protocol for accurate measurement.134
Checklist for Accurate Measurement of BP135,136
Key Steps for Proper BP Measurements
Specific Instructions:
Step 1: Properly prepare the patient
1. Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 min.
2. The patient should avoid caffeine, exercise, and smoking for at least 30 min before measurement.
3. Ensure patient has emptied his/her bladder.
4. Neither the patient nor the observer should talk during the rest period or during the measurement.
5. Remove all clothing covering the location of cuff placement.
6. Measurements made while the patient is sitting or lying on an examining table do not fulfill these criteria.
Step 2: Use proper technique for BP measurements
1. Use a BP measurement device that has been validated, and ensure that the device is calibrated periodically.
2. Support the patient’s arm (eg, resting on a desk).
3. Position the middle of the cuff on the patient’s upper arm at the level of the right atrium (the midpoint of the sternum).
4. Use the correct cuff size, such that the bladder encircles 80% of the arm, and note if a larger- or smaller-than-normal cuff size is used.
5. Either the stethoscope diaphragm or bell may be used for auscultatory readings.137,138
Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/hypertension
1. At the first visit, record BP in both arms. Use the arm that gives the higher reading for subsequent readings.
2. Separate repeated measurements by 1–2 min.
3. For auscultatory determinations, use a palpated estimate of radial pulse obliteration pressure to estimate SBP. Inflate the cuff 20–30 mm Hg above this level for an auscultatory determination of the BP level.
4. For auscultatory readings, deflate the cuff pressure 2 mm Hg per second, and listen for Korotkoff sounds.
Step 4: Properly document accurate BP readings
1. Record SBP and DBP. If using the auscultatory technique, record SBP and DBP as onset of the first Korotkoff sound and disappearance of all Korotkoff sounds, respectively, using the nearest even number.
2. Note the time of most recent BP medication taken before measurements.
Step 5: Average the readings
1. Use an average of ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP
Step 6: Provide BP readings to patient
1. Provide patients the SBP/DBP readings both verbally and in writing.
Clinical Recommendations
2017 Hypertension Clinical Practice Guidelines4
Recommendation for Accurate Measurement of BP in the Office (Guideline Section 4)
1. For diagnosis and management of high BP, proper methods are recommended for accurate measurement and documentation of BP. (Class 1, Level of Evidence: C-EO)

ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CDU, care delivery unit; DBP, diastolic blood pressure; HCO, home care organization; QCDR, Qualified Clinical Data Registry; and SBP, systolic blood pressure.