I was asked by my nursing supervisor to *not* be specific when charting a cardiac assessment. She indicated that much beyond "heart rate regular" was something she didn't want. I'm trying to figure out what needs to be said, and how, in the nurses notes so I do it right. For example: If you heard a systolic murmur at the aortic area, what would you chart? Another example: Let's say you hear a S4 gallop heard best at the 5th intercostal; how would you chart that properly without being "specific?" (Assuming your patient was showing no other signs of distress or whatever). Or, what if you're hearing an irregular heartbeat? Wouldn't that require that you chart that it WAS irregular and additional assessments such as being affected by inspiration, tissue perfusion, etc., so you aren't charting your patient is in trouble and you went on down the hall? I'm confused what should be said beyond "HRR." Thanks for anyone who answers!
That was my confusion, too. I felt like if there were implications involved, such as the S3 you mentioned that could indicate CHF, then wouldn't I also state "S3 gallop" and do a pulmonary assessment, fluid balance, etc.? Or, in a functional heart abnormality, wouldn't the baseline assessment be invaluable if there were a change? If nurse Mary comes behind me and I've charted a Grade 3 murmur over the aorta and it is now a grade 5 murmur with bruits, wouldn't that tell someone to DO something? Or what if there's a dx of some kind that supports the sounds you're hearing? Wouldn't you look like a idiot if you charted HRR when they had, for example, atrial fib? The supervisor's points were (1) not even a doctor charts that kind of thing and (2) charting specifics like "systolic murmur" is diagnosing, and (3) if someone saw that kind of charting, they'd think something was wrong and that they needed to follow up. Well, DUH! I'd hope so!
Last edit by Youda on Aug 8, '02
Aug 8, '02
I'm going to take a guess as to why a NM would say that. If you chart an abnormality, then further testing would be required to r/o any problems...and the hospital doesn't want to loose any money ya know. Many times there will be no problem to find...leaving the hospital to eat the cost, as the insurance wouldn't pay now nor would they authorize any procedures especially if a patient is not hospitalized for a cardiac problem.
I had a manager tell me something similar when I did HHC. All we were allowed to chart was HRR or HRI. Nothing more about the heart sounds. I was told it was b/c without a ECG that a person couldn't really be sure that that is what they were hearing. ??????. I did stop charting "S" sounds but continued to chart flutters, gallops and murmurs. I also expounded on what the irregularity sounded like..exp. Irreg. rythm Q 3rd beat. Also continued to chart tissue perfusion, etc. to show that the patient was not in any distress. Would call the doc with any suspisions and of course charted that too. My super also said something about having to f/u if an abnormaility was found and that many nurses didn't do the f/u leaving the company and the nurses open to liability. Ugh! F/U IMO is one of the most important things we do as RN's!! Just another way of trying to stop us from doing what we need to do to care for our patients properly! A management ploy of FORCING task oriented nursing upon us....IMO, it's just more of the same set up to prove that they can hire less educated people to do our job.
I am hoping that you don't work on a cardiac unit Youda. ??
Last edit by flowerchild on Aug 8, '02