3.4 Sample Documentation

Sample Documentation of Expected Findings

Blood pressure was 120/80 mmHg on the left arm with the patient in a seated position using a manual cuff.

Sample Documentation of Unexpected Findings

Blood pressure reading was collected with routine vital signs and noted to be 160/95 in the right arm. Blood pressure was retaken in the left arm after the patient rested for 5 minutes and was 154/93. Patient reports no history of hypertension and no current blood pressure medications.  Patient denies dizziness, headache, visual changes, and light-headedness. Dr. Smith was notified, and an order for furosemide 20 mg was received.