Cardiac Assessment Documentation

[Youda]

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!

[disher]

What is the NM more concerned about specific documentation or your assessments? If the NM's major concern is that your assessments are perceived as medical rather than nursing than maybe you could ask the medical staff how they want it adressed when you notice abnormal values.

[Jenny P]

I believe in charting what I hear and see, reporting it to the MD and charting that also. It is up to the doc to order follow up tests and procedures, NOT us OR THE HOSPITAL! I do not see how our charting our observations AND that we notified the doc of abnormal sx could increase either our liability or the hospitals'. We are not the diagnosticians, we are the nurses caring for the pt.

The supervisor was wrong UNLESS she feels that the nurse is charting something that makes no sense: ie: that an aortic murmur was heard at the apex of the heart. Maybe she'd prefer that murmurs are charted as "soft murmur heard over 2nd ICS at Rt. sternal border" instead of "grade 2/5 aortic murmur at 2nd ICS at Rt sternal border", or "extra heart sound heard over 5th ICS" instead of "S4 at 5th ICS" (in my experience, S4s usually aren't heard that far down in the chest as they are an atrial sound). Something to think about.

[Youda]

I charted on a recent MI patient, "murmur heard best at left 4-5th intercostal" which really isn't very specific. I thought that was pretty generic as it was. I proceeded to chart tissue perfusion, nail beds, edema, turgor, respiratory, etc., all the right stuff. She took issue that I put in there the LOCATION (left 4-5th intercostal) as being "too specific." She was concerned about followup not being done on abnormals by other nurses who "wouldn't know" whether or not that was "important." Or that, through their own assessments wouldn't continue to assess cardiac function and for those who want to just chart the percentage of meal eaten, I think. She kept saying, "It's great that you have these skills, but . . ." In other words, don't use the skills you have. How can I possibly assess a patient, especially a recent MI, and leave out cardiac? It's obvious that me and the NM need to talk again. I will certainly use the excellent points and ideas you have all given.

[Stargazer]

If you're taking care of cardiac pts in your unit, and you are the only nurse who knows how to do-- and document-- a proper cardiac assessment, then your NM has much bigger problems than what you're charting, and I can certainly understand why she's looking ahead to the day when you'll all be testifying in a malpractice case, because it's inevitable.

If it's really true that the other nurses in your unit don't have advanced cardiac assessment skills, why not offer to hold an inservice and teach them yourself?

[Jenny P]

Youda, do what you have to and chart your findings. Have you considered offering to teach a class on cardiac assessment to your co-workers? You could do it formally for CEU's, or informally-- I've done both. Maybe point out to her that you shouldn't have to dumb down, but instead help your co-workers learn new skills so you can improve your patients' outcomes. After all, this is what the current research is showing-- that nurses (especially skilled and educated nurses) save lives! And that should help your hospital's bottom line, right?

[Youda]

Just a follow-up for all you wonderful nurses who gave me such good answers: I finally had a talk with the NM this morning. I told her I disagreed with her on her viewpoint and explained why (using some of the ideas you all gave me, plus a view points of my own). She sat quietly and listened to me and the speech I'd reheorificed in front of the mirror (I'm such a woose!). When I was done, she said, "OK, you convinced me." She agreed that the documentation from everyone was really bad, but something she hadn't started to work on yet since there were bigger issues she was needing to address. She said that she might use some of my documentation in an inservice because sometimes "you need an example for people to follow." Life is good!

[DelGR]

CoooL. That is great news.

[Stargazer]

Woo! Nice job, Youda!

And by the way--someone who identifies a problem, researches solutions, confronts her boss about it, convinces her of her point of view, AND gets the desired response, can in no way, shape or form be considered a wuss!

[cargal]

At last, sense prevails! Congratulations on a fine job, youda. You are an inspiration, as are the other fine nurses here.

[maizey]

Congratulations on standing your ground for your patients. That makes you a wonderful nurse in my eyes. Thank you for caring.