CV Documentation Flashcards
(3 cards)
How do you document normal heart findings?
Auscultation: RRR, no M. No carotid bruits
regular rate and rhythm, no murmur
What should be the first thing listed in your Objective Section?
General: Pt appears conscious, alert, appears to be in pain
What should be the second thing listed in your objective section?
VITALS - hr, rr, t, etc