CV Documentation Flashcards
1
Q
How do you document normal heart findings?
A
Auscultation: RRR, no M. No carotid bruits
regular rate and rhythm, no murmur
2
Q
What should be the first thing listed in your Objective Section?
A
General: Pt appears conscious, alert, appears to be in pain
3
Q
What should be the second thing listed in your objective section?
A
VITALS - hr, rr, t, etc