Chest Pain

Diagnosis: Chest Pain

Applicable for MSDRGs: 313

MD documentation should address:

1. Presenting symptoms: cardiac rhythm normal, tachy or bradycardia; SOB/dyspnea (on exertion); lung sounds; respiratory effort and rate; syncopal or presyncopal episodes; palpitations; chest/jaw/arm/or shoulder pain; angina or unstable angina; emotional stress
2. CXR findings: (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. Cardiac study findings (i.e. diastolic/systolic dysfunction; ejection fraction; valve disorders)
4. EKG: new findings and subsequent changes
5. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure, hyper- or hypocarbnia)
6. Lab values: hypoperfusion of renal or hepatic system; electrolyte abnormalities (DO NOT USE ARROWS)
7. Possible contributing conditions: CAD, prior MI; cardiac/vascular surgery; implanted cardiac device; anemia; HTN (benign, malignant/accelerated)
8. Origin of CP (cardiac vs non-cardiac)
9. Cardiac CP: if angina, specify stable or unstable; and source (i.e. CAD, aortic stenosis, cardiomyopathy, MI, etc.)
10. Non-cardiac CP source: musculoskeletal; pleuritic; GERD, etc.
11. Evidence of encephalopathy and cause if known (metabolic, specific organ dysfunction)
12. Treatment with medications, procedures or therapies

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