You cannot record both a controlled and an uncontrolled rate in PTOS. The idea is that you are capturing the initial vitals. For respiratory rate, you are capturing the initial respiratory rate, which will be either controlled or uncontrolled.
In the event that documentation supports that the patient does have a documented rate of zero, and an assisted rate of 18 we can or cannot use the documentation of ZERO for unassisted because of the following in the PTOS book: “Do not enter ‘0’ if controlled rate is entered.”?
You are correct that these are optional elements that are NOT required to be completed. PTSF will work with ESO to modify or remove this check.
How are centers (or how can we) handle when a patients height and weight are documented on the EPIC timeline of one of our own network hospitals? A referring facility within our network documented on the same timeline for this patient transferred to our facility. Unfortunately these were not re-documented during the encounter for treatment of this patients traumatic injury. Just wondering if we are able to use or not?
You are not to use data from the referring facility here. You must record the first height and weight documented within 24 hours of ED or hospital arrival at your facility.