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Sample Documentation of Unexpected Cardiac & Peripheral Vascular Findings. Patient reports increase in breathing difficulty and increased swelling of bilateral lower extremities over the last three days. Diminished pulses (+1) bilaterally and pitting edema (+2) in the bilateral lower extremities.
Use the “CPR Vitals” Power Tool to simplify documentation. Heart rate and respiratory rate defaulted to 0 (zero). If the heart rate is not zero because you are providing CPR to an infant with a pulse less than 60, document the actual pt’s pulse. Document the patient’s ECG rhythm.
Sample Documentation of Unexpected Cardiac & Peripheral Vascular Findings Patient reports increase in breathing difficulty and increased swelling of bilateral lower extremities over the last three days.
Sample Documentation of Unexpected Cardiac & Peripheral Vascular Findings. Patient reports increase in breathing difficulty and increased swelling of bilateral lower extremities over the last three days. Diminished pulses (+1) bilaterally and pitting edema (+2) in the bilateral lower extremities.
Our CVICU Report Sheet template is meticulously crafted to enhance the efficiency and accuracy of documenting and communicating vital patient care information within the Cardiovascular Intensive Care Unit.
Here’s a quick guide to documenting an exam of the heart. The main elements of the heart exam include: Observation – Look for jugular venous distention. Note any obvious chest deformities (we will discuss documentation of these findings in later pats of our series).
We have listed below helpful documentation tips. Name & date of birth (DOB) are preferred. Please also include the member’s legal name if they go by a nickname. The patient has an ejection fraction of 55%. The specific date range that the treatment(s) was completed should be included.
