Patient presents with a systolic heart murmur.  Onset, duration, and character of the murmur were documented.  Auscultation revealed a systolic murmur, the grade and location of which were carefully noted (e.g., grade II/VI systolic ejection murmur at the second right intercostal space).  Radiation of the murmur, if present, was also documented.  The patient's symptoms, if any, associated with the murmur, such as chest pain, shortness of breath (dyspnea), dizziness, syncope, or palpitations were detailed.  Relevant past medical history, including congenital heart disease, rheumatic fever, valvular heart disease, hypertension, hypertrophic cardiomyopathy, and previous cardiac procedures, was reviewed.  Family history of heart conditions was also explored.  Differential diagnoses considered include innocent murmurs, physiological murmurs, aortic stenosis, mitral regurgitation, pulmonic stenosis, tricuspid regurgitation, and ventricular septal defect.  Diagnostic evaluation may include electrocardiogram (ECG or EKG), echocardiogram, cardiac catheterization, and chest x-ray.  Treatment plan will be based on the underlying cause of the murmur and may include medication management, lifestyle modifications, or surgical intervention.  Patient education regarding the diagnosis, prognosis, and treatment options was provided.  Follow-up care was scheduled as appropriate.  ICD-10 codes for systolic heart murmur (e.g., R01.1, R01.2) and associated conditions will be used for medical billing and coding.  This documentation is compliant with clinical documentation improvement (CDI) guidelines.