Which vital signs documentation is incomplete?

• A. Radial pulse regular at 84/min
• B. Respirations observed as even, nonlabored at 20/min with client in supine position
• C. BP 124/82 mm Hg, lying in bed
• D. Temporal temperature 36.9° C (98.4° F)

Answer: (C)

Vital signs documentation must include the measurement site and the position or context of the measurement to ensure accuracy and reproducibility. In this case, the blood pressure entry gives a reading and notes that the patient is lying in bed, but it does not specify which arm was used or whether the arm was supported at heart level. These details matter because blood pressure can differ between arms and can change with the arm’s position relative to the heart, so without them the entry isn’t fully informative. Other entries show complete documentation by including the pulse site with rate and rhythm, the respirations with rate and effort and the patient’s position, and the temperature with site and value.