Any note: how it gets read

How to chart vitals someone else took

Your login says you took the vitals at the minute you typed them. How to chart who really measured them, when, and every recheck.

7 min read built on 0 cases updated 2026-11-05

Written by a med-surg RN, ten years, day shift. Why there is no name on it · How this guide is made

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The aide hands you a slip with a blood pressure on it. A student calls out a fingerstick. The day nurse took a set right before report. You type the numbers in under your login, and now the chart says you took them, at the minute you typed. Recheck and get something different, and you have two readings to explain.

Key points

  • Write down who measured it (name and role) and when. Your login only shows who typed it.
  • Set the flowsheet column to when it was measured. Don't leave it at whenever you sat down to type.
  • If your EHR has a taken by or performed by field, use it. No field? Put the same information in the row comment or a short note.
  • Recheck gives you a different number? Keep both. Chart the second one as its own entry with its own time and your name, plus whatever might explain the gap: arm, cuff size, position, device, recent activity, food or meds.
  • Say which number you acted on and what you did: held the med, gave the med, called the provider, told the charge nurse.

What to write

How it often gets charted What works better
BP 142/88, HR 76, T 98.4, RR 18, SpO2 96% entered at 0840, no commentColumn set to 0715. Comment: VS obtained by J. Ramos, CNA, at 0715. Entered by this RN at 0840.
BG 52 entered with no sourceBG 52 per fingerstick by S. Lee, nursing student, at 1130, observed by this RN. Pt diaphoretic, shaky. 4 oz juice given 1132.
First BP of 84/52 deleted, replaced with 118/70BP 84/52 L arm, automatic cuff, sitting, obtained by CNA M. Diaz at 0800. Recheck by this RN at 0812: 118/70 R arm, manual cuff, sitting, adult regular cuff. Pt denies dizziness. Lisinopril given per parameters based on 0812 reading.
VS rechecked, WNLRecheck at 1415 by this RN: HR 104 (CNA reading at 1400: HR 128). Pt had just returned from walking to the bathroom at 1400. Will recheck at 1445.
Vitals per CNAVS per K. Owens, CNA, 2000. HR 118 reported to this RN at 2005. Rechecked at 2010: HR 116, irregular, pt denies chest pain. Dr. Patel notified at 2015.
BG 210, coveredBG 210 at 1700, obtained by day RN A. Nguyen and reported at handoff 1900, not previously charted. Entered by this RN at 1910 with time 1700. Sliding scale coverage per MAR given by A. Nguyen at 1715.
Morning BP recorded as 0600 because that's when the round startedBP 168/94 obtained by CNA at 0640 (column set to 0640, actual time)

A few notes on the examples:

  • Give the role with the name: CNA, nursing student, LPN, day RN, patient's home monitor. Each one tells the reader something different about the reading.
  • If you watched it happen (common with students), say so: observed by this RN.
  • On a mismatch, the useful part of the note is whatever explains it: which arm, cuff size, manual or automatic, position, time since walking, eating, insulin, or a PRN.
  • You don't have to decide which reading was "right." Chart both. Say which one you acted on.

Template

Vitals or glucose entered on someone else's behalf

[DATE] [TIME OF ENTRY]
Vital signs obtained by [NAME], [ROLE: CNA / LPN / RN / NURSING STUDENT], at [TIME MEASURED].
BP [VALUE] [ARM], [MANUAL / AUTOMATIC], [POSITION]. HR [VALUE]. RR [VALUE]. T [VALUE] [ROUTE]. SpO2 [VALUE] on [ROOM AIR / O2 DEVICE AND FLOW].
[IF GLUCOSE: BG [VALUE] by fingerstick at [TIME MEASURED], [OBSERVED / NOT OBSERVED] by this RN.]
Values reported to this RN at [TIME REPORTED]. Entered by this RN at [TIME OF ENTRY] with measurement time [TIME MEASURED].
[ACTION TAKEN, OR: No action required per current orders.]
[YOUR NAME], [CREDENTIALS]

Recheck that does not match the first reading

[DATE] [TIME OF RECHECK]
Initial reading: [PARAMETER] [VALUE] at [TIME], obtained by [NAME], [ROLE], [ARM / SITE], [DEVICE], [POSITION].
Recheck by this RN at [TIME]: [PARAMETER] [VALUE], [ARM / SITE], [DEVICE], [CUFF SIZE IF BP], [POSITION].
Possible factors: [E.G. RECENT AMBULATION / MEAL / INSULIN / PRN GIVEN AT TIME / DIFFERENT CUFF / NONE IDENTIFIED].
Patient assessment: [SYMPTOMS OR DENIES SYMPTOMS, SKIN, MENTAL STATUS].
[MED NAME] [GIVEN / HELD] based on [WHICH READING] per [ORDER PARAMETERS].
[PROVIDER NAME] notified at [TIME] of both readings. Orders received: [ORDERS OR NONE].
Plan: recheck at [TIME].
[YOUR NAME], [CREDENTIALS]

Message to the charge nurse when readings keep not matching

[CHARGE NURSE NAME],
On [DATE], vitals for [ROOM / PATIENT INITIALS] were reported to me as [VALUES] at [TIME], obtained by [NAME / ROLE].
My recheck at [TIME] was [VALUES] using [DEVICE / MANUAL].
This is the [FIRST / SECOND / THIRD] time this shift that a reported reading and a recheck differed by [AMOUNT].
Both readings are charted with times and sources.
Could we check the [DEVICE NUMBER / CUFF / GLUCOMETER] and review the vitals workflow for this unit?
[YOUR NAME], [CREDENTIALS], [UNIT], [EXTENSION]

Words to avoid

Word or phrase Why it causes trouble Use instead
VS WNLNo numbers, no source, no time. Nobody can check it later.The actual values, who took them, and the time
per CNADoesn't say which CNA or whenper [name], CNA, at [time]
rechecked with no numberReads as if the first value was wrong, without showing anythingRecheck at [time]: [value], [arm, cuff, position]
stableA conclusion, not a finding. Stable compared to what?The two readings and their times
BP down / BG betterSays it changed but not by how muchBP 148/90 at 0900, 132/84 at 1000
tolerated well after a med held or given on parametersHides which reading you went byGiven based on BP [value] at [time]
Leaving the entry timestamp as isThe chart shows the time you typed, not the time it was measuredChange the column or row time to when it was measured

The aide's numbers go in under your name

The usual mistake looks harmless. The aide's numbers go in under your name with no comment, timed when you typed them. Later you recheck, get something different, and either type over the first value or skip charting the recheck because it "came out fine."

The problem is mechanical. One login folds four facts into one: who measured, when they measured, who entered it, when it was entered. Without a note, nobody reading the chart later can pull those apart. The aide takes a BP at 0715, you enter it at 0840, and the chart shows it as yours at 0840. If metoprolol went out at 0800 on that number, it now looks like you gave the med before anyone had checked a pressure.

Overwriting is a second problem. A first reading of 82/50 and a recheck of 118/72 tell the provider something. Maybe a bad cuff, maybe orthostasis, maybe a patient who looks fine one minute and doesn't the next. Delete the first number and that's gone. Keep only the first, and the chart shows a hypotensive patient nobody responded to. Either way the record stops matching what happened at the bedside. The next nurse reads a trend that isn't real.

Glucose works the same way, just faster. The student gets a fingerstick of 52, juice goes in, the recheck fifteen minutes later is 98. That's an ordinary hypoglycemia episode, handled well. If only the 98 makes it into the chart, there's no record the episode happened.

Bottom line

Your login shows who typed the number. The note has to show who measured it, when, and every reading you got.

Official guidance

  • Abnormal vital signs and sudden changes get reported to the nurse right away. They don't wait for the routine handoff. If someone else measured it, that report is your cue to recheck and chart. (NCBI Bookshelf, NurseOnShift)
  • Read vital signs as a pattern over time. That only works if each reading sits at its real time and both readings survive a mismatch. (Lippincott NursingCenter, NurseOnShift)
  • Chart the value you actually measured, with details like position, route, and oxygen. Don't round it toward what you expected. (NurseOnShift, NurseChartingPro)

What this rests on

No published decision turned up for this question. We looked, and the searches are in the record. So this article stands on published guidance and on how the question is asked on the floor, not on a court opinion. That is a weaker footing than the rest of the guide, and you should know it before you rely on it. The decisions behind the other articles are all in one place.

From nurses online

Quoted as written. Opinion, not a source.

  • They then told me that nobody had even been by to check their vitals all morning. These patients are completely AAOx3, no confusion, no dementia or Alzheimer’s or anything like that. I describe the CNA to them just to double check that she hadn’t been in and they assured me that no, I was the only p

    r/nursing on Reddit: CNA falsifying vital signs reddit

  • That's how the cna protects themselves ... be documentation from the CNA. RNs take and chart their own vitals all the time; as long as it's done, it doesn't matter who does it....

    “Don’t ever chart [out of range vitals]!” : r/nursing reddit

  • The doc reviews VS, thinks everyone needs their meds increased, and now I got Geraldine going down on me as I walk her to the bathroom because her BP is 73/42. But, instead of making the nurses take the vital signs, they just made sure the CNA checked them after breakfast. Is there a reason that the

    r/nursing on Reddit: Tele unit CNAs can no longer take vitals reddit

  • I think it’s relevant too because I don’t want to chart something that I didn’t do especially when no one knows who took them. What if they didn’t take them right and I catch the blame bc I charted it? ... so the concern isn’t really the shredding of the paper with the vitals but documenting the vit

    r/nursing on Reddit: Nurse encouraged to falsify medical records by employer reddit

Other guides

Advice, not law.