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Documentation Form

Health Assessment Score: ____/2pts.

Nursing 210

System: Cardiovascular

Subjective Findings: Review Health History in text ** Follow guidelines on prior documentation forms

Chief Complaint:

History of Present Illness:


Past Medical History:


Family History:


Personal and Social History:


Objective Findings:

Inspection/Palpation:

*Identify landmarks: Suprasternal notch, Angle of Louis, 2nd rib, 2nd intercostal space, clavicles

*Inspect & palpate apical impulse: note presence/absence and exact location

* Inspect for pulsations

*Palpate for lifts/heaves/thrills in 3 positions on the chest

Auscultate:

*Auscultate areas (APPTM): aortic area, pulmonic area, second pulmonic area, tricuspid area, and mitral area (with both diaphragm and bell)

*S1 – where is it heard best

*S2 – where is it heard best

*S3 and/or S4

* Note extra heart sounds (clicks, friction rub, murmurs)

*Apical heart rate (for full minute) – note rate and rhythm using diaphragm

*Auscultate in left lateral position with bell of stethoscope for S3 and/or S4 and other low-pitched sounds

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SAMPLE Documentation Form

Health Assessment Score: ____/2pts.

Nursing 210

System: Peripheral Vascular System

Subjective Findings: ** Follow guidelines on prior documentation forms

Chief Complaint:

History of Present Illness:


Past Medical History:


Family History:


Personal and Social History:


Objective Findings:

Inspect:

*Inspect jugular vein for distension

*Inspect carotid artery for pulsations

*Inspect extremities (upper and lower) for sufficiency of arteries and veins:

*color/skin texture

*hair distribution

*general size and symmetry

*presence/absence of edema

*varicose veins/venous patterns

Palpate:

*Palpate extremities bilaterally (upper and lower) for temperature

*Palpate for edema

*Palpate carotid artery bilaterally one side at a time noting rhythm and force

*Brachial Pulse: presence, rhythm, force

*Radial Pulse: presence, rhythm, force

*Femoral Pulse: presence, rhythm, force

*Popliteal Pulse: presence, rhythm, force

*Posterior Tibial Pulse: presence, rhythm, force

*Dorsalis Pedis Pulse: presence, rhythm, force

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