Chart 3.2. – Blood pressure measurement at the physician's office.

The patient should seat comfortably in a quiet environment for 5 minutes before BP measurement can begin. Explain the procedure to the individual and instruct them not to talk during the measurement. Possible doubts should be clarified before or after the procedure.
Make sure the patient does or has NOT: • Have a fuller bladder; • Exercised within the last 60 minutes; • Had coffee or alcohol or eaten; • Smoked within the last 30 minutes.
Three BP measurements should be taken, at 1 to 2 minute intervals; additional measurements should only be performed if the first two readings differ by > 10 mm Hg. Record in the patient's chart the mean of the last two BP readings, without rounding it up or down, and the arm used for the measurement.
Additional measurements may have to be performed for patients with unstable BP due to heart arrhythmias. In patients with AF, auscultatory methods are preferable, since most automated devices have not been validated for BP measurement.*
Use properly sized cuffs for arm circumference.
The cuff should be positioned at heart level. The patient should have their palm up and their clothing should not compress their arm. Patients should have back and forearm supported, legs uncrossed, and feet planted on the ground.
Measure BP in both arms during the first visit, preferably both simultaneously, to detect possible differences between arms. The arm with the higher reading provides the reference value.
In investigating orthostatic hypotension, first measure BP (preferably in supine position, after the patient has been supine for 5 minutes; if the individual is unable to remain in supine position, the measurement may alternately be taken with the patient sitting, though that position is not ideal), then take additional BP readings 1 minute and 3 minutes after the person stands up. BP should measured at rest and standing for all patients in their first visit and also considered in subsequent visits for older adults, diabetes patients and dysautonomic patients, as well as those on any antihypertensive medication.
Record the heart rate. To rule out arrhythmia, use palpation of the pulse.
Inform the patient of the BP reading.

AF: atrial fibrillation; BP: blood pressure.^*Most automated devices register the highest individual systolic blood pressure reading instead of averaging out several cardiac cycles for AF patients, leading BP to be overestimated.