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Chest Pain Documentation Pearls

Blog_ChestPainDocumentationPearls_EKGnurseTabletChartHosp_260x200px.jpgPatients with chest pain are a common and constant challenge to clinicians, whether in the office, clinic, urgent care or emergency department. The clinical presentations may be confusing, the differential diagnoses are myriad, and not all patients with chest pain will have a serious underlying etiology.

Lawsuits involving the care of patients with chest pain are frequent and make up the costliest group of malpractice cases in Emergency Medicine. The cornerstone of high-quality, defensible care consists of a systematic approach coupled with comprehensive documentation. The essence of liability reduction in the care of patients with chest pain is to construct a medical record that provides a thorough, clear and logical explanation for your thoughts and actions. EMR systems can now incorporate clinical decision support systems that assist the clinician to achieve optimal documentation for patients with chest pain and other acute complaints.

The following are a few of the key items to address in the chart documentation.

History of Present Illness

  • Location of Pain: Where it started and where it is now
  • Radiation of Pain: To arm(s), shoulder(s), neck, back, jaw
  • Quality of Pain: Sharp, dull, tight, pressure, burning, tearing, heavy, achy
  • Associated Signs & Symptoms: Nausea, vomiting, diaphoresis, SOB, dizziness, palpitations, DOE, PND, orthopnea, cough, sputum, hemoptysis, fever, chills, weight loss, fatigue
  • Context: During exertion, stress, respiration or movement
  • Modifying Factors: What helps or hurts

Past Medical History

  • Medical: Previous stress test, angina, MI, “blockages,” valve disease
  • Procedures: Angiogram, angioplasty, stenting, bypass surgery

tom-syzekRisk Factors

  • CAD Risk Factors: History of coronary artery disease, family history, diabetes, hypertension, smoking, LVH, high cholesterol, cocaine use
  • Pulmonary Embolus Risk Factors: Immobilization, recent surgery, history of DVT or PE, malignancy, pregnancy now or recent, trauma to pelvis or legs, OCP use + smoking, CHF, COPD, obesity, hypercoagulable
  • Thoracic Aortic Dissection Risk Factors: Hypertension, disease of aorta or valve, connective tissue disease (e.g., Marfan syndrome), pregnancy, ASHD, smoking
  • Pericarditis/Myocarditis Risk Factors: Infection, autoimmune disease, recent MI or cardiac surgery, malignancy, radiation therapy to chest, uremia, drugs (procainamide, hydralazine, isoniazid), history of pericarditis
  • Pneumothorax Risk Factors: Prior pneumothorax, Valsalva maneuver, lung disease, smoking
  • Pneumonia Risk Factors: COPD, altered consciousness or impaired gag reflex, neuromuscular disease

Physical Exam

  • Vital Signs: BP in both arms if chest pain radiates to the back
  • Lungs: Rales, rhonchi, wheezes, breath sounds, quality & regularity of respirations, rubs
  • Cardiovascular: JVD, pulses, bruits, rhythm, clicks, murmurs, gallops, PMI, rub
  • Chest Wall: Appearance, tenderness, lesions
  • Abdomen: Appearance, distention, bruits, organomegaly, pulsatile masses, tenderness
  • Extremities: Color, edema, pulses, tenderness, temperature, signs of IV drug use

ED Course

  • Record the results of treatment and medications given.

Medical Decision-Making

  • Address the results of all tests ordered.
  • ECG – compare to previous ECG.
  • Review and acknowledge the EMS run sheet and nursing notes.
  • Document a differential diagnosis and discuss your reasoning regarding the likelihood (or not) of serious causes, including angina, MI, pulmonary embolus, thoracic aortic dissection, pericarditis/myositis, pneumothorax, pneumonia.


  • For Admitted Patients: Record who was consulted and when.
  • For Discharged Patients: Include time-specific and person-specific (i.e., PCP or cardiologist) discharge instructions.
  • Provide clear instructions that include specific reasons to return to the ED (e.g., any return of pain, change in character, increased severity, SOB, sweating, palpitations).


Most chest pain malpractice suits occur with patients who are discharged rather than admitted. Along with clear, time- and person-specific discharge instructions, the most important tool to providing good care and reducing liability is plain and simple communication with patients and their families. Tell them what you are thinking, who to see next and when, reasons to return, and that THEY ARE WELCOME TO RETURN FOR CARE ANY TIME THEIR CONDITION WORSENS.




Categories: Emergency Medicine, EMR & Decision Support, Urgent Care


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