Documenting Respiratory, Cardiovascular and Neurological Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function. Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care.

Guidelines for General Observations

Respiratory system

After examining the respiratory system, document the following:
Assessed Rate and rhythm or respirations
Auscultated The lung fields
Inspected Sputum for color, consistency and other characteristics.

Cardiovascular system

After examining the cardiovascular system, document the following:
Auscultated For heart sounds
Assessed Heart rate and rhythm
Assessed The color and temperature of the extremities
Assessed The peripheral pulses; record the quality by “number”
Inspected For edema (pitting; record by “number”)
Inspected The neck veins (distention)

Neurological system

After examining the neurological system, document the following:
Inspected The patient’s head for evidence of trauma
Assessed The patient’s level of consciousness, including orientation to time, place, person and situation
Assessed The patient’s ability to follow commands
Assessed The patient’s pupillary reactions and cranial nerve function
Assessed The patient’s extremities for movement and sensation


Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

  • Have a claim made against your professional services.
  • You will be named in a group lawsuit – whether as part of a larger group of health care professionals and/or included with your health care facility.
  • Witness a negligent act by another health care professional during the course of a normal work day.
  • Be deposed to testify on behalf of yourself, your employer or colleague.


No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties. However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy. It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

  1. Failure to follow standards of care
  2. Failure to use equipment responsibly
  3. Failure to document
  4. Failure to assess and monitor the patient
  5. Failure to communicate.


I will discuss these five common allegations in the coming blog posts, so stay in touch!

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