.CV_NORMAL

Skilled CV assessment: HR {##} reg; BP {##/##} {arm/position} within ordered range; S1/S2 nl, no S3/S4/murmur/rub; no JVD; pulses 2+ symmetric; cap refill <3s; {no edema / baseline ___ edema}; weight {##} lb stable vs target; denies CP/palpitations/dyspnea/orthopnea/dizziness. RN judgment applied to detect early decompensation and evaluate the cardioactive regimen given {dx}. Continued skilled monitoring indicated.

.CV_ASSESS

HR {##} {reg/irreg}; apical {##} if irregular; BP {##/##}; S1/S2 nl, extra {S3/S4/rub}; JVD {present/absent}; pulses DP {#/#} PT {#/#}; cap refill {## s}; edema {1+–4+} {site}; weight trend {+/- ## lb}; SpO2 {##}%; DOE after {## ft}.

.CV_SKILL

Applied {PRN diuretic/nitro} per order; pre/post monitored; orthostatics {pos/neg}; rhythm/rate validated; reconciled meds incl OTC NSAIDs/decongestants; coordinated {electrolytes/INR} per order.

.CV_TEACH

Reviewed {HF zones/daily weights >2–3 lb·day or >5 lb·wk/low-Na label reading/home BP technique/anticoag precautions/nitro protocol} with {patient/caregiver}; method {teach-back/return-demo}; mastery {##}%; AVS provided.

.CV_COORD

Provider notified at {time} re {finding/value meeting parameter}; reported {content}; order received {details}; patient response {response}; reassessment {when}.

.CV_SAFETY

Call 911 promptly for chest pain or suspected ACS, severe SOB or pink frothy sputum, syncope, weight gain >{##} lb, or new weakness/speech change; take prescribed nitroglycerin per order while awaiting EMS.

.CV_HOMEBOUND

Homebound: DOE limits ambulation to ~{##} ft with {device}; requires {assist} and {##} min rest after exertion; leaving home a considerable and taxing effort.

.CV_NECESSITY

Skilled nursing required today to {skilled action} for {RN-level reason} given {dx}, resulting in {measurable effect}.