CHEST PAIN DOCUMENTATION
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files (3)RUBRICFORGRADING.docx
Week7SHFocusedChestPainTemplate.docx
WK7SAMPLE.pdf
RUBRICFORGRADING.docx
RUBRIC FOR GRADING
Subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. = Documentation is detailed and organized with all pertinent information noted in professional language....Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
Objective Documentation in Provider Notes - this is to be completed using the documentation template that is provided. Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use "WNL" or "normal". You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result - Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). = Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language....Each system assessed is clearly documented with measurable details of the exam.
Week7SHFocusedChestPainTemplate.docx
Name:
Section:
Week 7
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Include last Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
Cardiovascular/Peripheral Vascular:
Respiratory:
Gastrointestinal:
Musculoskeletal:
Psychiatric:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
Cardiovascular/Peripheral Vascular: Always include the heart in your PE.
Respiratory: Always include this in your PE.
Gastrointestinal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during the SH assignment.
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.
© 2021 Walden University
WK7SAMPLE.pdf
1
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
Name
Institution
Patient Initials: Brian Foster, Age: 58, Race: Caucasian American, Sex: Male
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SUBJECTIVE DATA
Chief Complaint (CC): “Sporadic chest pain.”
History of Present Illness (HPI): BF is a 58-year-year old Caucasian male who came to the
hospital complaining of pain at the center of the chest, which begun in the past month. He reports
that the pain goes away after several minutes. The pain happened during work, and he felt
tightness and pain. The patient reports the pain increases during the activity. He rates the pain as
5/10.
1. Location- the center of the chest
2. Quality- several” minutes
3. Quantity or severity-5 out of 10
4. Timing, including onset, duration, and frequency-past month
5. Setting in which it occurs-Pain happened with yard work as well as taking stairs
6. Factors that have aggravated or relieved the symptom- activity
7. Associated manifestations—tight, uncomfortable, and crushing pain.
Medications: Lopressor 100mg once daily for high blood pressure, Lipitor 20mg once daily for
high cholesterol, fish oil as a supplement 1200mg once a day, Atorvastatin 20 mg daily.
Allergies: Reports being allergic to codeine
Past Medical History (PMH): One year ago, the patient was diagnosed with high blood
pressure and high cholesterol
Past Surgical History (PSH): No report of past surgery.
Sexual/Reproductive History: heterosexual, and sexually active.
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Personal/Social History: The patient does not smoke tobacco. Reports drinking two times a
week. He does not exercise regularly. He drinks about two liters of water a day. His diet is
composed of meat, veggies, and granola. Denies recreational use of medications.
Immunization History: All vaccinations are current, and he received a tetanus vaccine in 2014.
Significant Family History: Dad has high blood pressure and high cholesterol dies at age 75
because of colon cancer. Mom has a history of diabetes mellitus. Sister is asthmatic. Maternal
granddad died of stroke at 54*. Maternal grandma- passed away due to breast cancer at 65.
Paternal grandma- passed away at 78 due to pneumonia. Paternal grandpa died at 85 due to
asthma.
Review of Systems:
General: Denies sweating at night, fever, and feeling tired. Reports increase of weight.
HEENT- denies ear and eye problems. Denies having problems during swallowing and sore
throat.
Cardiovascular/Peripheral Vascular: Denies having blood clots, murmur Angina, palpations,
and irregular heartbeats
Respiratory: Denies shortness of breath, coughing, and report having chest pain.
Gastrointestinal: Denies diarrhea, vomiting, and constipation.
Musculoskeletal: Denies having pain in the joints.
Psychiatric: Denies suicidal thoughts.
Objective data
Physical Exam:
Vital signs: Left arm 146/88 mmhg right arm 146/90 mmhg MAP- 109 mmhg HR 104 BPM
RR- 19 o2 sat - 98% RA Temp- 36.7C
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General: The patient is oriented, alert, and well-groomed and responds to questions
appropriately.
HEENT- Head is symmetric, nose and mouth moist and pink.
Cardiovascular/Peripheral Vascular: S1 S2and S3 present. There is Gallup.
Respiratory: Breathing is quite evident as well as unlabored. Upon auscultation, breath sounds
are all clear upper. Fine crackles in lower bases of L/R lungs.
Gastrointestinal: The stomach region of the patient is soft, on –tender and there are Round, soft,
non-normative bowel sounds in all quadrants. In addition, there are no abdominal bruits and
tenderness on both light and deep palpation. The abdomen organs are Tympanic. The liver is 7
cm and palpable. Spleen is bilateral, and the kidneys are not palpable.
Musculoskeletal: No abnormal finding was recorded.
Neurological: Alert and oriented x 3. The patient can move all body parts and extremities
Skin: Warm, waterless, pink, and whole. No tenting
Diagnostic Test/Labs:
EKG test- shows regular sinus rhythm and no ST changes.
X-rays of chest to determine an abnormality.
Telescope to find out for abnormal sounds on heart and chest.
ASSESSMENT:
Differential Diagnosis
1. Angina pectoris is a chest pain that happens when one part of the heart is not getting adequate
plasma and oxygen. The symptoms of this disease are chest and shoulders pain. Treatment for
this disease involves relieving signs by resting as well as using angina drugs. Another treatment
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involves practicing healthy lifestyles, which in turn improves the overall health of the person.
The patient may have this condition because he reports having chest pain episodes that begun a
month ago, which is a symptom of angina
2. Myocardial Infarction is a heart attack characterized by a lack of blood and oxygen in heart
measles. The condition can lead to heart damage as well as death if not treated. The condition
can be controlled by medication. Myocardial infarction is caused by unhealthy eating habits,
shock, and electrolyte imbalances. The patient may have this condition because, during
percussion, there were fine crackles on the chest and Gallup in the heart
3. Costochondritis-This is a cartilage inflammation that links the rib and sternum. The pain that
causes this disease is the same as that of a heart attack. Costochondritis is also called chest pain,
in many cases, may accompany the pain. The disease has no known cause. Therefore, treatment
is focused on easing patient pain while waiting for the disease to recover on its own. Some of the
symptoms are coughing and chest pain. The patient may have this condition because he has tight
and uncomfortable chest pain, which begun last month.
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References
Anderson, J. L., & Morrow, D. A. (2017). Acute Myocardial Infarction. New England Journal of
Medicine, 376(21), 2053–2064. https://doi.org/10.1056/nejmra1606915
Ong, P., Camici, P. G., Beltrame, J. F., Crea, F., Shimokawa, H., Sechtem, U., Kaski, J. C., &
Bairey Merz, C. N. (2018). International standardization of diagnostic criteria for
microvascular angina. International Journal of Cardiology, 250, 16–20.
https://doi.org/10.1016/j.ijcard.2017.08.068
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Schumann, J. A., Tanuj Sood, & Parente, J. J. (2021, July 10). Costochondritis. Nih.gov;
StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532931/
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