Chest Pain Documentation Example

Overview

Chest pain is one of the most high-stakes documentation challenges in emergency medicine. The note must do three things simultaneously: reflect the breadth of your differential, document your independent data interpretation, and demonstrate the medical necessity for your disposition decision. Notes that document findings without documenting reasoning leave you exposed - both to payer audits and to liability. This guide shows you how to write a chest pain note that does all three.

HPI Example

Patient is a 52-year-old male with history of hypertension and hyperlipidemia presenting with 2 hours of substernal chest pressure that began at rest. Rates pain 7/10. Describes a pressure-like quality radiating to the left arm. Associated with mild shortness of breath and diaphoresis. Denies nausea, vomiting, palpitations, syncope, or cough. Last ate 4 hours ago. No prior history of MI or cardiac catheterization. Current medications: lisinopril 10mg daily, atorvastatin 40mg daily. NKDA.

ROS Example

Constitutional: Diaphoresis. Denies fever, chills, fatigue. Cardiovascular: Substernal chest pressure, left arm radiation. Denies palpitations, PND, orthopnea, lower extremity swelling. Respiratory: Mild dyspnea on presentation, improving. Denies cough, hemoptysis, pleuritic component. GI: Denies nausea, vomiting, heartburn, abdominal pain. Neurologic: Denies syncope, pre-syncope, dizziness, focal neurologic symptoms. Extremities: Denies leg swelling, unilateral calf pain.

Physical Exam Example

Vitals: T 98.4°F, HR 96, BP 152/88, RR 18, SpO2 97% RA General: Alert, oriented, visibly uncomfortable, mild diaphoresis, speaking in full sentences Cardiovascular: Regular rate and rhythm. Normal S1/S2. No murmurs, rubs, or gallops. No JVD. Radial pulses 2+ and equal bilaterally. Respiratory: Clear to auscultation bilaterally. No crackles or wheezing. Abdomen: Soft, non-tender. No epigastric tenderness. Extremities: No lower extremity edema. Calves non-tender bilaterally. Skin: Diaphoretic. No rash.

MDM Example

Problem: Chest pain - high-risk presentation; ACS must be excluded Number of Diagnoses/Management Options: 1 acute illness with potential threat to life - High Data Reviewed: EKG obtained within 10 minutes of arrival and independently interpreted by me (ST depressions in V4–V6, no STEMI criteria). Troponin I x2 ordered (initial pending). CXR reviewed (no pulmonary edema, no pneumothorax, no widened mediastinum). Case discussed with attending physician. Risk: High - potential need for urgent cardiac intervention; decision regarding hospitalization required Overall MDM Level: High (supports 99285 / 99215 equivalent) Clinical decision-making: 52-year-old male with cardiac risk factors presenting with classic anginal symptoms. HEART Score: History 2 (highly suspicious), EKG 1 (non-specific repolarization changes), Age 1 (45–65), Risk Factors 2 (≥3 known), Troponin pending = working score ≥6, high risk. Aspirin 325mg PO given. Cardiology notified. Continuous cardiac monitoring and IV access ×2 established. Admission to telemetry pending troponin x2. STEMI protocol not activated - no qualifying STE on EKG.

Smart Phrase

.CHESTPAIN CC: Chest pain HPI: [Age] [sex] with PMH of [HTN/HL/DM/CAD/prior MI] presenting with [X] hours of [substernal pressure/sharp/pleuritic] chest pain. Pain [X]/10, [radiation to left arm/jaw/back/no radiation]. [Associated SOB/diaphoresis/nausea]. Denies [syncope, palpitations, cough, fever]. Last ate [X] hours ago. Exam: VS: [vitals]. Cardiac: [RRR, no MRG / murmur described]. Resp: [CTA bilaterally / crackles at bases]. Abd: [NT, no epigastric tenderness]. Ext: [no edema, calves NT]. EKG (interpreted independently): [NSR, no acute ST changes / ST depressions in leads ___ / ST elevations in leads ___ / LBBB]. HEART Score: H:[0-2] E:[0-2] A:[0-2] R:[0-2] T:[0-2] = Total [X/10] - [Low/Moderate/High] risk. A/P: Chest pain. [ACS on differential - admitted to telemetry / Low risk per HEART score - discharged with strict return precautions and PCP f/u within 72h / Musculoskeletal - discharged]. [ASA given / Troponin serial / Cardiology consulted / STEMI protocol not activated].

Documentation Tips

• Always document your EKG interpretation in the note with the time obtained. 'EKG ordered' is not the same as 'EKG interpreted by me.'
• For High MDM, you must document independent interpretation of each test ordered - labs, imaging, and EKGs all count separately.
• Document your HEART Score or equivalent risk stratification tool explicitly. It demonstrates systematic clinical reasoning and is auditor-friendly.
• Disposition reasoning must appear in the note - why admitted vs. discharged, and what the plan is contingent on (e.g., 'pending troponin ×2').
• If cardiology was consulted, document the consultant's name, time of consult, and the specific recommendation received.

Related Documentation Guides

• URI Documentation Template
• Sports Physical Documentation Template