Clinical Resources

Vitals

Overview

The Vitals section captures key physiological measurements that provide an immediate snapshot of a patient’s overall health status.

These measurements help clinicians monitor trends, identify early signs of deterioration, and support clinical decision-making.

Vital signs are fundamental to nearly every medical encounter, from routine checkups to acute care, and are a critical input for risk assessment and treatment planning.

Clinical Data in Source Documents

Vital signs are typically documented in dedicated sections of the clinical record such as Vitals, Physical Exam, or Nursing Assessment .

They may appear in tabular form, as part of narrative notes, or integrated within encounter summaries.

Common measurements include:

• Blood Pressure (BP) - Systolic and diastolic readings, often recorded with patient position (e.g., sitting, standing).
• Heart Rate (HR) - Measured in beats per minute, sometimes with rhythm descriptors (e.g., regular, irregular).
• Respiratory Rate (RR) - Breaths per minute, with qualifiers such as unlabored or labored.
• Temperature - Recorded in Fahrenheit or Celsius, specifying the method (oral, axillary, tympanic, etc.).
• Height and Weight - Used to calculate Body Mass Index (BMI).
• Body Mass Index (BMI) - Reflects weight relative to height and is critical for assessing obesity or malnutrition.
• Oxygen Saturation (SpO₂) - Percentage of oxygen saturation in the blood, essential for respiratory assessment.

These values may be accompanied by context such as the date, time, encounter type, or the healthcare professional who performed the measurement.

JSON Output

The platform extracts and organizes vitals into a standardized JSON format, ensuring that each measurement is consistently represented for downstream analysis and interoperability.

The structured output typically includes:

• Blood Pressure: Combined systolic/diastolic value (e.g., 110/60).
• Heart Rate: Numeric value with optional rhythm description (e.g., 80 (Regular)).
• Respiratory Rate: Numeric value with descriptors if available (e.g., 12 (Unlabored)).
• Temperature: Body temperature with standardized unit (e.g., 98.4 °F).
• Height and Weight: Numeric values, which may be used to compute BMI when available.
• BMI: Calculated if height and weight are present.
• Oxygen Saturation: SpO₂ expressed as a percentage.

This extraction layer ensures that measurements from unstructured notes or tables are converted into a clean, machine-readable structure.

Additional metadata such as section header or encounter reference may also be captured to preserve the clinical context.

{
  "vitals": [
    {
      "blood_pressure": "118/70 mmHg",
      "heart_rate": "76 (Regular)",
      "respiratory_rate": "16 breaths per minute",
      "temperature": "98.3 °F",
      "height": "5 ft 5 in",
      "weight": "148 lb",
      "bmi": "24.6",
      "oxygen_saturation": "95%",
      "page_number": 2
    }
  ]
}

FHIR Output

Each extracted vital sign is mapped to the FHIR Observation resource under the vital-signs category.

The FHIR representation allows seamless integration into electronic health records (EHRs) and downstream analytics systems.

Key mappings include:

• Measurement Type → Observation.code – Identifies the specific vital sign (e.g., Blood pressure panel , Heart rate , Temperature ).
• Value and Units → Observation.valueQuantity or Observation.component.valueQuantity – Stores the numeric result along with standardized units (e.g., mmHg for blood pressure, beats/min for heart rate, °F or °C for temperature).
• Status → Observation.status – Indicates whether the measurement is final , amended , or entered-in-error .
• Category → Observation.category – Categorizes the data as a vital sign for interoperability and easy retrieval.
• Patient Reference → Observation.subject – Links the observation to the corresponding patient record.
• Encounter Reference → Observation.encounter – Associates the measurement with the specific clinical visit or hospitalization.
• Performer → Observation.performer – Identifies the clinician or staff member who recorded the vital sign.
• Component Structure → Observation.component – Used when a measurement consists of multiple related values, such as systolic and diastolic blood pressure.

{
  "fullUrl": "urn:uuid:56208e87-5a02-4de0-9c9d-e83508e801b0",
  "resource": {
    "resourceType": "Observation",
    "status": "final",
    "category": [
      {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/observation-category",
            "code": "vital-signs"
          }
        ]
      }
    ],
    "code": {
      "text": "Respiratory rate"
    },
    "subject": {
      "reference": "Patient/b17aaab1-311c-4d98-9c93-030277d0aeb0"
    },
    "encounter": {
      "reference": "Encounter/1dd92df1-17c3-4a55-9b3d-409d422f2c9e"
    },
    "valueQuantity": {
      "value": 16,
      "unit": "breaths/min",
      "system": "http://unitsofmeasure.org",
      "code": "/min"
    },
    "performer": [
      {
        "reference": "Practitioner/4dfd859c-d4c2-45cc-b27f-6f7d919765cc"
      }
    ],
    "id": "56208e87-5a02-4de0-9c9d-e83508e801b0"
  }
}