Question

While evaluating a patient complaining of chest pain, your physician tells you that the hear sounds are normal. Where would you document this?

Answer 1

Heart sounds are documented under the auscultation section of a patient's medical record, where the normal 'lub-dub' sounds indicate proper functioning of the heart valves, observed through the use of a stethoscope.

Step-by-step explanation:

When a physician informs you that the heart sounds of a patient complaining of chest pain are normal, you would document this finding under the auscultation section of the patient's medical record. Auscultation is a technique where the stethoscope is used to listen to the heart's sounds, commonly referenced as 'lub' and 'dub'. These sounds result from the closing of the atrioventricular and semilunar valves, respectively. It is an essential part of the physical examination and assessing the state of a patient's heart. If the heart sounds deviate from this normal lub-dub pattern, it can indicate the presence of heart pathologies such as valve disorders, which may require further diagnosis through an echocardiogram.