Heart auscultation involves listening to the rhythmic sounds generated by the heart and blood flow using a stethoscope. This auditory assessment is a foundational element of the physical examination, providing immediate, non-invasive insight into cardiac function. Clinicians must convert subjective auditory findings into a standardized, objective written record for communication and tracking. This documentation ensures findings are accurately shared among healthcare providers and compared over time to monitor a patient’s condition.
Understanding Normal Heart Sounds
The normal cardiac cycle produces two distinct sounds. The first heart sound, S1, marks the beginning of ventricular contraction (systole) and is caused by the simultaneous closure of the mitral and tricuspid valves. This closure prevents blood from flowing backward into the atria. S1 is typically heard as a single, lower-pitched sound.
The second heart sound, S2, follows S1 and signals the end of systole and the start of ventricular relaxation (diastole). It is caused by the closure of the aortic and pulmonic semilunar valves as the ventricles finish ejecting blood. These two sounds establish the fundamental rhythm and rate of the heart. Normal findings are crisp, clearly distinguishable, and occur in a predictable sequence, establishing a baseline of “regular rate and rhythm.”
Standardizing Location and Timing
Effective documentation requires specifying where a sound is heard most clearly, correlating to the location of the heart valves on the chest wall. Clinicians systematically auscultate five primary areas to isolate sounds from each valve:
- Aortic area (second right intercostal space).
- Pulmonic area (second left intercostal space).
- Erb’s point (third left intercostal space), useful for hearing S2 and some murmurs.
- Tricuspid area (fourth or fifth left intercostal space near the sternum).
- Mitral area, or apex (fifth left intercostal space at the midclavicular line).
Specifying the location links the sound to a specific valve or chamber. This spatial information must be combined with temporal information, defining the sound’s timing within the cardiac cycle. The cardiac cycle is divided into systole (the period between S1 and S2 when the ventricles contract) and diastole (the period between S2 and the next S1 when the ventricles relax and fill). Documenting whether an abnormal sound occurs during systole or diastole is crucial, as timing helps narrow the potential causes.
Documenting Abnormal Sounds
When an abnormal sound, such as a heart murmur, is detected, standardized terminology is used to describe its characteristics. The intensity of a systolic murmur is graded on a six-point scale, expressed as a fraction (e.g., Grade 3/6). A Grade 1/6 murmur is barely audible, while a Grade 4/6 is loud and is the first grade associated with a palpable vibration on the chest wall, known as a thrill.
The description must also include the sound’s quality, using terms like “harsh,” “blowing,” “rumbling,” or “musical” to convey its texture. Documentation notes the pitch (high, medium, or low) and any radiation, which describes the direction the sound spreads from the point of loudest intensity. For example, an aortic valve murmur often radiates up to the neck, while a mitral murmur may radiate to the axilla. Extra heart sounds, known as gallops, are documented using their specific nomenclature, S3 and S4. An S3 sound occurs early in diastole, suggesting a problem with ventricular volume or rapid filling. An S4 sound occurs late in diastole and is associated with a stiffened ventricle. The presence of a pericardial friction rub, a high-pitched, scratchy sound, is also noted with its location and timing, often indicating inflammation of the heart’s outer sac.
The Structure of the Clinical Record
The findings from auscultation are compiled into a succinct clinical record using standardized medical shorthand. For a normal finding, documentation is often condensed to a single, abbreviated phrase. The most common shorthand is RRR, which stands for Regular Rate and Rhythm, indicating that S1 and S2 are present, distinct, and occur at a consistent pace. A typical normal entry reads: “S1/S2 audible, RRR, no rubs, gallops, or murmurs.” This confirms the presence of normal sounds and the absence of major abnormalities.
For an abnormal finding, the detailed description is integrated into the note, following the structure of timing, intensity, location, and radiation. An example of an abnormal entry is: “2/6 systolic ejection murmur noted at the RUSB [Right Upper Sternal Border], harsh quality, radiating to the neck.” This structure provides all necessary data points for a complete clinical picture.