Heart sounds are the vibrations created by the heart’s mechanical actions as blood moves through its chambers and valves. These sounds, particularly those generated by the closure of heart valves, provide an auditory window into cardiac function. Listening to these sounds, a practice known as auscultation, is a core aspect of cardiac assessment. Documenting these findings involves recording specific characteristics, forming a crucial part of a patient’s health record.
Why Heart Sound Documentation Matters
Accurate documentation of heart sounds is an integral part of patient care. These records aid in the early detection of cardiovascular conditions, such as valvular heart disease or heart failure. They allow healthcare professionals to monitor the progression of known cardiac issues and assess treatment effectiveness. Consistent documentation fosters clear communication among providers, ensuring access to comprehensive information.
Essential Elements of Heart Sound Documentation
Documenting heart sounds involves capturing key characteristics of the heart’s activity. The primary normal heart sounds, S1 and S2, are noted. S1, the “lub” sound, signifies the closure of the mitral and tricuspid valves at the beginning of ventricular contraction. S2, the “dub” sound, marks the closure of the aortic and pulmonic valves at the end of ventricular contraction.
Observations include the intensity of these sounds (normal, diminished, or accentuated) and their timing within the cardiac cycle. The pitch and quality of the sounds are also recorded. Specific anatomical locations on the chest are noted as the sites where sounds are best heard:
Aortic area (second intercostal space, right sternal border)
Pulmonic area (second intercostal space, left sternal border)
Erb’s point (third intercostal space, left sternal border)
Tricuspid area (fourth intercostal space, left sternal border)
Mitral area (fifth intercostal space, midclavicular line)
Standardized Language for Describing Sounds
Standardized terminology is fundamental for heart sound documentation. Normal heart sounds, S1 and S2, are described by their presence and relative intensity, such as “normal intensity” or “diminished.”
When extra sounds like murmurs are detected, they are graded by intensity using the six-point Levine scale. A Grade I murmur is very faint, while a Grade VI is extremely loud and audible with the stethoscope off the chest. Murmurs are also categorized by their timing within the cardiac cycle: systolic (between S1 and S2), diastolic (between S2 and S1), or continuous.
Additional descriptors include the murmur’s shape (crescendo, decrescendo, crescendo-decrescendo, or plateau), quality (blowing, harsh, rumbling, or musical), and pitch (high, medium, or low).
Documenting Specific Heart Sound Abnormalities
Documenting abnormal heart sounds requires precise language. For murmurs, the entry includes timing (systolic, diastolic, or continuous), intensity grade (I/VI to VI/VI), and the anatomical location where it is heard most distinctly. The radiation of the murmur (e.g., neck or axilla) is also recorded.
Further elements include the murmur’s pitch and quality. Noting changes with specific maneuvers, such as patient position or breathing, provides additional diagnostic clues.
Gallops, specifically S3 and S4 heart sounds, are documented by their presence and timing. An S3, or ventricular gallop, occurs in early diastole, sounding like “lub-dub-dah” (“Kentucky”). An S4, or atrial gallop, occurs just before S1, creating a “ta-lub-dub” sound (“Tennessee”).
While S3 can be normal in children and young adults, its presence in adults over 40 can indicate heart dysfunction. S4 is considered a sign of a stiffened ventricle. Other abnormal sounds like clicks (short, high-pitched) or friction rubs (scratchy noises) are also documented, with notation of their timing and location.