# Standard Operating Procedure: [CLINICAL PROCEDURE NAME, e.g. Rooming a Patient and Vital Signs Collection]

## Document Control

| Field | Entry |
|---|---|
| SOP ID | [SOP-CLIN-001] |
| Version | [1.0] |
| Effective Date | [YYYY-MM-DD] |
| Owner | [CLINIC MANAGER / NURSE MANAGER NAME] |
| Approver | [MEDICAL DIRECTOR NAME, CREDENTIALS] |
| Next Review Date | [YYYY-MM-DD — annually, or upon guideline/regulation change] |
| Location(s) | [CLINIC / DEPARTMENT / EXAM ROOMS] |

## 1. Purpose

Standardize [PROCEDURE, e.g. patient rooming and vital-signs collection] so every patient is identified correctly, measured consistently, and documented completely in [EHR SYSTEM], supporting safe handoffs to providers and compliance with HIPAA and [STATE/ACCREDITATION REQUIREMENTS].

## 2. Scope

- **Applies to:** [ROLES, e.g. medical assistants and LPNs] performing [PROCEDURE] at [LOCATION] during scheduled visits and walk-ins.
- **Does not apply to:** [e.g. "triage of emergent presentations, covered by SOP-CLIN-009; pediatric vitals under age 2, covered by SOP-CLIN-012"].
- Nothing in this SOP replaces clinical judgment; escalate concerns to [PROVIDER/RN] at any time.

## 3. Definitions

| Term | Definition |
|---|---|
| Two-identifier check | Confirming patient identity using two identifiers (full name + date of birth) — never room number |
| PHI | Protected Health Information under HIPAA — any identifiable health data, spoken, written, or electronic |
| Standard precautions | Baseline infection-control practices (hand hygiene, gloves when contacting body fluids) applied to every patient |
| [CLINIC TERM] | [DEFINITION] |

## 4. Responsibilities

| Role | Responsibility |
|---|---|
| Medical Assistant / [ROLE] | Performs rooming and vitals per this SOP; documents in [EHR] before leaving the room |
| RN / Charge Nurse | Handles escalations; validates competency [ANNUALLY] via skills checklist [FORM ID] |
| Provider | Reviews rooming data; owns clinical decisions |
| Clinic Manager | Maintains this SOP, equipment calibration schedule, and training records |
| Privacy Officer | [NAME/CONTACT] — receives suspected HIPAA incidents within [TIMEFRAME] |

## 5. Required Materials and Equipment

- Calibrated vital-signs equipment: [BP monitor with adult/large/pediatric cuffs, thermometer with probe covers, pulse oximeter, scale] — calibration checked per [SCHEDULE]
- Hand sanitizer (60%+ alcohol) and gloves at point of care
- [EHR] access under **your own login** — credential sharing is prohibited
- EPA-registered disinfectant wipes for between-patient cleaning [PRODUCT, CONTACT TIME]

## 6. Procedure

Example steps below describe adult rooming and vitals; adapt to your clinic's visit types.

1. **Perform hand hygiene** before patient contact (WHO Moment 1). Sanitizer for at least [20 SECONDS] or soap and water if hands are visibly soiled.
2. **Call the patient by first name only** in the waiting area (limits PHI disclosure). Confirm identity in private with **two identifiers**: "Please tell me your full name and date of birth." Match both against the [EHR] chart before proceeding.
3. **Escort and settle the patient.** Close the exam-room door. Verify the chart on screen is the patient in the room — wrong-chart entries are a reportable event per [INCIDENT SOP].
4. **Screen per visit protocol.** Complete [SCREENINGS, e.g. fall risk, depression screen (PHQ-2), medication reconciliation, allergy review]. Read allergies back to the patient to confirm.
5. **Measure vital signs.**
   - Blood pressure: patient seated, back supported, feet flat, arm at heart level, correct cuff size (bladder covers ~80% of arm circumference), after [5 MINUTES] rest. No talking during measurement.
   - Temperature, pulse, respirations, SpO2, weight [AND HEIGHT IF DUE] per device instructions.
6. **Document immediately** in [EHR] fields — not on paper scraps. Late entries must be flagged as such; never pre-chart values.
7. **Escalate out-of-range values before leaving the room.** Notify [RN/PROVIDER] immediately for: BP ≥ [180/120], SpO2 < [92%], temp ≥ [103°F/39.4°C], HR < [50] or > [120], or any acute distress. [ADJUST THRESHOLDS TO YOUR MEDICAL DIRECTOR'S ORDERS.]
8. **Set the room flag** to "ready for provider" per [FLAG SYSTEM], and give a brief verbal or [EHR] handoff for anything abnormal.
9. **Between patients:** discard disposables, disinfect contact surfaces (exam table, BP cuff, doorknob) observing the wipe's [CONTACT TIME], change table paper, perform hand hygiene.

## 7. Privacy and HIPAA Notes

- Discuss PHI only in private areas; screens angled away from public view; lock the workstation ([WINDOWS+L]) when stepping away.
- Access only the records of patients you are treating — audit logs are reviewed [FREQUENCY].
- Suspected breach (misdirected fax, lost device, overheard disclosure): report to the Privacy Officer within [24 HOURS] per [BREACH SOP]. HIPAA requires breach notification without unreasonable delay, no later than 60 days.

## 8. Safety and Compliance Notes

- Standard precautions apply to every encounter; sharps go directly into the sharps container — never recap needles ([OSHA 29 CFR 1910.1030] Bloodborne Pathogens).
- Equipment calibration and cleaning logs retained [PERIOD]; training and competency records retained per [STATE] requirements.
- [ACCREDITATION BODY, e.g. AAAHC/Joint Commission] standards referenced: [LIST].

## 9. Related Documents

- [SOP-CLIN-009 — Emergent Triage]
- [SOP-IC-001 — Hand Hygiene and Standard Precautions]
- [FORM COMP-01 — Annual Skills Competency Checklist]

## 10. Revision History

| Version | Date | Author | Summary of Changes | Approved By |
|---|---|---|---|---|
| [1.0] | [YYYY-MM-DD] | [NAME] | Initial release | [NAME, MD] |
| [ ] | [ ] | [ ] | [ ] | [ ] |

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