The Heart Exam Tab (figure 28) is specific for cardiac findings. For those that never examine the heart of the patient, the tab can be skipped with no entries being made.
Figure 28
In order to activate the Heart tab window, place a check in the Heart box at the upper left. If the findings are all Normal, select Normal in the drop down box to the right of the Heart Check Box. If the findings are Abnormal, select Abnormal in the drop down box which will activate the other options on this window.
If the Rate or Rhythm is abnormal, place a check in the appropriate box. When Murmurs are detected, place a check in the Murmurs box to activate the type of murmur selections.
For the Heart Sounds checklist, place a check next to all the items that apply to the patient. The Heart Sounds checklist ends with an asterisk (*) and a blank line so the examiner can add in any item that is needed but not yet on the list. The new item(s) entered becomes a permanent addition to the list so it will be available for any other patient that requires it.
The column on the right is for Auscultation Findings and consists of 3 drop down selection boxes. Note that next to each drop down box there is a square with 3 dots. This opens a window in which the contents of the drop down box can be edited, adding new items, modifying existing items, and deleting those that are never used.
•Heart
•Carotid Artery
•Abdominal Aorta