Documentation Guidelines

• Physical findings: Vital signs; right atrial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, CO, systemic vascular resistance, pulmonary vascular resistance; skin temperature, color, dampness; presence or absence of jugular vein distension or hepatojugular reflux, ascites, edema, pulmonary crackles or wheezes, S3 or S4, or murmurs; intake and output; daily weight; mental status

• Laboratory results: Electrolyte, complete blood count, and ABG results

• Response to medications such as diuretics, nitrates, inotropes, and oxygen

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