Documentation Guidelines

• Physical findings of the cardiopulmonary and renal systems: Heart and breath sounds, vital signs, capillary refill, pulmonary artery pressure readings if applicable, intake and output, daily weights

• Presence of complications that are associated with mitral stenosis: Atrial fibrillation, pulmonary edema, heart failure

• Response to medications used to treat the symptoms and complications that are associated with mitral stenosis

620 Mononucleosis, Infectious

• Tolerance to activity

• Response to surgical intervention: Wound healing, fluid balance, pulmonary artery pressures and cardiac output, urine output, chest tube drainage

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