Angina and Chest Pain [Documentation Suggestions]

  • List history of conditions that might have caused pain (e.g., coronary artery disease, respiratory illness, trauma, ulcer disease, etc.).
  • Describe clinical signs and symptoms (e.g., substernal chest pain, pericardial pressure, heartburn, stabbing pain, localized tenderness, etc.).
  • Document work-up (e.g., EKG, serum cardiac markers, stress test, electrolytes, coronary arteriogram, chest x-ray, etc.).
  • Document treatment (e.g., morphine, O2, nitroglycerine, ASA, H2 blockers, heparin, etc.).
  • Note etiology (e.g., acute myocardial infarction, GERD, pleurisy, CAD, stress, etc.).
  • Specific type of angina (e.g., stable, unstable, post-infarction, etc.).

Additional notes:



Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: 7/7/03)