Assess cardiac status against the ordered parameters and document the skilled judgment:
Heart rate and rhythm (regularity, apical vs radial where indicated), blood pressure against the ordered parameters, and any orthostatic change.
Volume status: daily weight compared to the prior value and the parameter, edema (location/grade), lung sounds (bibasilar crackles), jugular venous distension, and a new S3 where assessed.
Symptoms — dyspnea, orthostatic pain/lightheadedness, palpitations, activity tolerance — and the response to cardiac medications within the ordered parameters.
MDS-supportive data
IV cardiac medications are coded in MDS Section O; anticoagulant and other cardiac medication days in Section N; weight in Section K; the cardiac diagnosis in Section I. The record must document weights, the medication response, and the assessment so the MDS is supported.
