CV Documentation Flashcards by Colin Hemond

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How do you document normal heart findings?

Auscultation: RRR, no M. No carotid bruits

regular rate and rhythm, no murmur

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What should be the first thing listed in your Objective Section?

General: Pt appears conscious, alert, appears to be in pain

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What should be the second thing listed in your objective section?

VITALS - hr, rr, t, etc

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CV Documentation Flashcards

(3 cards)