3.4 Sample Documentation

Sample Documentation of Expected Findings

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

Sample Documentation of Unexpected Findings

Blood pressure reading on right arm 160/95. Blood pressure reading left arm 154/93 after patient rested 5 minutes. Reports no history of hypertension and currently not taking any blood pressure medications. Denies dizziness, headache, visual changes, or light-headedness. Dr. Smith notified of all of above and order for furosemide 20 mg PO now received.


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