Really stupid charting question

cracklingkraken, ASN, RN · Feb 21, 2016

The charting I've done at the hospital says something similar, "S1S2 audible" and there's an "other" option that has a note section where you can list additional sounds.

chare · Feb 21, 2016

We use Epic at my facility. When we document heart sounds we have the ability to select multiple options (S1, s2; gallop, rub, etc.). For example, using the information provided in your post, I would select the following items: S1, S2; gallop; and murmur.

However, much of this will depend on which program you are using, and how it is setup. Your facility's policies and procedures should provide further detail on how and what you should chart.

tsm007 · Feb 21, 2016

We use Epic at my facility. When we document heart sounds we have the ability to select multiple options (S1, s2; gallop, rub, etc.). For example, using the information provided in your post, I would select the following items: S1, S2; gallop; and murmur.
However, much of this will depend on which program you are using, and how it is setup. Your facility's policies and procedures should provide further detail on how and what you should chart.

It is Epic that I am using. I guess my bigger question is when would you not check s1, s2?

chare · Feb 21, 2016

It is Epic that I am using. I guess my bigger question is when would you not check s1, s2?

Again, a lot will depend on your facility's policies and procedures.

First, Epic is designed to chart by exception. What this means is that your facility should have determined what "within defined limits (WDL)" means. If your patient meets these criteria, then select WDL for that assessment category and move to the next, without selecting any individual items. I personally don't like doing this and often don't select either WDL or X, but rather document my individual assessment findings.

To answer your question regarding when you wouldn't select S1, S2. If you can't identify S1, S2, then don't chart it. There could be any number of reasons why you might not hear S1, S2. If hour patient has a prominent murmur, that might be all you hear (e.g., patient with a VAD, mechanical valves, murmur, rub, etc.). However, the presence of an adventitious heart sound doesn't mean that the patient can't have normal heart sounds. In the PICU, in our cardiac patients, it is not uncommon to hear rubs, murmurs, gallops, and clicks (depending upon history) with a normal S1, S2.

And I want to emphasize this. Document what you hear. Don't copy forward what the nurse on the previous shift documented, unless you agree with her or his findings. If you don't hear an S1, S2, don't chart it. If you're not sure what you hear, don't document anything. Or document "other" and try and describe it in the comments. it doesn't matter what the nurse before you charted, chart your assessment.

ETA: This wasn't a "stupid charting question." If you don't know, you don't know. Never be afraid to ask, or worse, stop asking questions.

tsm007 · Feb 22, 2016

Again, a lot will depend on your facility's policies and procedures.
First, Epic is designed to chart by exception. What this means is that your facility should have determined what "within defined limits (WDL)" means. If your patient meets these criteria, then select WDL for that assessment category and move to the next, without selecting any individual items. I personally don't like doing this and often don't select either WDL or X, but rather document my individual assessment findings.
To answer your question regarding when you wouldn't select S1, S2. If you can't identify S1, S2, then don't chart it. There could be any number of reasons why you might not hear S1, S2. If hour patient has a prominent murmur, that might be all you hear (e.g., patient with a VAD, mechanical valves, murmur, rub, etc.). However, the presence of an adventitious heart sound doesn't mean that the patient can't have normal heart sounds. In the PICU, in our cardiac patients, it is not uncommon to hear rubs, murmurs, gallops, and clicks (depending upon history) with a normal S1, S2.
And I want to emphasize this. Document what you hear. Don't copy forward what the nurse on the previous shift documented, unless you agree with her or his findings. If you don't hear an S1, S2, don't chart it. If you're not sure what you hear, don't document anything. Or document "other" and try and describe it in the comments. it doesn't matter what the nurse before you charted, chart your assessment.
ETA: This wasn't a "stupid charting question." If you don't know, you don't know. Never be afraid to ask, or worse, stop asking questions.

Thank you! Thank you! You answered my question perfectly. I do chart what I hear. I guess in my head because I have never had a situation as of yet where I haven't heard s1 and s2 I couldn't think of a situation other than asystole where you wouldn't hear s1 and s2.

Here.I.Stand, BSN, RN · Feb 22, 2016

Well most people you would hear S1 and S2. Like chare said, someone with a VAD you just hear a steady whoosh. My son who was born with a VSD had a good holosystolic murmur, and rather than a "lub dup" you heard a "pfff." :) S2 got buried in the turbulance.

I typically just click "WDL." You could click S1, S2 and not be wrong, just a bit redundant.

tsm007 · Feb 22, 2016

Well most people you would hear S1 and S2. Like chare said, someone with a VAD you just hear a steady whoosh. My son who was born with a VSD had a good holosystolic murmur, and rather than a "lub dup" you heard a "pfff." :) S2 got buried in the turbulance.
I typically just click "WDL." You could click S1, S2 and not be wrong, just a bit redundant.

Thanks. A lot of this is I just haven't heard enough heart sounds. Up until 3 months ago I hadn't heard a murmur. And I was almost giddy when I realized hey, I think this is a murmur and checked the chart and realized I was right. I guess I hadn't realized a murmur could obscure s1 or s2. All the heart sounds I'd listened to online this was just a question that puzzled me. Now I get it. Yes, everyone does HAVE a s1 and s2, but not everyone can you HEAR an s1 and s2.