Cardiac Assessment Documentation

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    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!
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    I'm not sure what your supervisor's rationale is for not charting specifics of a cardiac assessment, but I would have to disagree with him or her.

    You bring up some salient points with regard to charting abnormals. If this is your baseline assessment, then you know you have other parameters you need to be checking as well. When you find abnormal heart sounds, do you report them and follow up with a 12-lead EKG or push for a cardiology consult? Your follow-up with an abnormal finding is crucial. Let's say you find S3 and S4 heart sounds--could it possibly signify CHF? How would that steer your assessment and care of the patient? If you hear a murmur over the aorta, could that mean aortic valve stenosis or insufficiency, and again, what are the implications for that patient? If we don't respond to abnormal findings, we are neglecting the patient and putting the patient at risk for further problems.

    I hope that answers your question. I would definitely challenge your supervisor's rationale, and if you get no satisfaction there, I would take it further. Good luck!
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    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
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    Howdy yall
    from deep in the heat of texas


    You have to do what is right in your mind and what you feel is right for the pts needs




    doo wah ditty
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    I would dearly love to know the supervisor's rationale also. Cripes, I have to constantly remind my folks to document MORE detailed assessments!

    The thing is, if you end up in a deposition or testifying in court because of an undesireable patient outcome, and you've got nothing more on your notes than "heart rate regular", then you're going to look negligent, careless, or stupid, not your supervisor. It's YOUR license on the line. If she continues to try to insist without giving you a good explanation, i would take it up with Risk Management.
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    Originally posted by Stargazer
    I would dearly love to know the supervisor's rationale also. Cripes, I have to constantly remind my folks to document MORE detailed assessments!

    The thing is, if you end up in a deposition or testifying in court because of an undesireable patient outcome, and you've got nothing more on your notes than "heart rate regular", then you're going to look negligent, careless, or stupid, not your supervisor. It's YOUR license on the line. If she continues to try to insist without giving you a good explanation, i would take it up with Risk Management.
    Stargazer actually hit the nail with the proper hammerhead here. That NM.....without revealing the ramifications of what she told her nurse to NOT chart, has been "schooled" by the "higher ups" to NOT have her staff chart so 'SPECIFICALLY' in CASE... there is ever a COURT DEPOSITION about a cardiac patient who happened to be treated by one of her staff nurses.

    What you chart.....can be questioned.....not charted......not questioned in a way that would make the hospital liable. It's not that your charting is WRONG....it's that your CHARTING is TOO POLITICALLY CORRECT and could possibly one day....maybe.....maybe not....be used in a court of law if a family member or that very patient wanted to say "said heart conditions were charted.....no one paid attention.....more serious stuff happened to patient that might not have IF......."

    When you chart THAT specifically, it DOES set the hospital up for more liabilities........and I'm not disagreeing with your charting assessment........but looking at it from the admin side of the house....this is your NMs rationale. :kiss
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    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
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    Originally posted by teeituptom
    You have to do what is right in your mind and what you feel is right for the pts needs

    I agree with Tom, and I would add that you must do what is in your best interest, as well, should you ever have to go to court. I have been a nurse since 1983, and NEVER have had a supervisor tell me how to chart. If your ears and experience tell you that there is a gallop, rub, murmur, squeak, whatever, I'd document it exactly the way you hear it, and where you hear it, and if the pt. is supine, on their side, leaning forward, etc. It is very possible that this person is jealous of your charting skills. Do what you know to be correct and don't bend. If she harrasses you about it, go to your union steward, or Chief Nurse.
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    Originally posted by cheerfuldoer


    Stargazer actually hit the nail with the proper hammerhead here. That NM.....without revealing the ramifications of what she told her nurse to NOT chart, has been "schooled" by the "higher ups" to NOT have her staff chart so 'SPECIFICALLY' in CASE... there is ever a COURT DEPOSITION about a cardiac patient who happened to be treated by one of her staff nurses.

    What you chart.....can be questioned.....not charted......not questioned in a way that would make the hospital liable. It's not that your charting is WRONG....it's that your CHARTING is TOO POLITICALLY CORRECT and could possibly one day....maybe.....maybe not....be used in a court of law if a family member or that very patient wanted to say "said heart conditions were charted.....no one paid attention.....more serious stuff happened to patient that might not have IF......."

    When you chart THAT specifically, it DOES set the hospital up for more liabilities........and I'm not disagreeing with your charting assessment........but looking at it from the admin side of the house....this is your NMs rationale. :kiss
    Renee,

    Unfortunately, I think you are right about the NM's rationale--unfortunate from the perspective of the patient. If we find and document an abnormal value, we are also obligated to follow it up by reporting it and following an accepted standard of care. I don't think anyone can go wrong with reporting an abnormal (which could, in fact, be baseline for the patient) and asking for the appropriate followup--EKG, cardiology consult, etc. This should always be accompanied by solid and thorough documentation of other parameters associated with the abnormal finding (i.e.--skin color, presence of chest pain, SOB, VS, tissue perfusion).

    This is a tough one.....but I generally choose to err on the side of charting the abnormal and whatever followup is necessary. Just my 2 cents...........
  13. 0
    Originally posted by cheerfuldoer
    When you chart THAT specifically, it DOES set the hospital up for more liabilities........and I'm not disagreeing with your charting assessment........but looking at it from the admin side of the house....this is your NMs rationale. :kiss
    Damn!!!


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