WHEN YOUR PATIENT complains of chest pain, act quickly to help determine whether it's caused by a disorder as benign as indigestion or as serious and life-threatening as acute myocardial infarction. Essential documentation for chest pain includes the date and time the pain started. Ask your patient about his pain, and record the responses using his own words, when appropriate. Also include the following:
* what he was doing when the pain started
* how long the pain lasted, if it had ever occurred before, and whether the onset was sudden or gradual
* any associated symptoms, such as nausea, vomiting, weakness, or shortness of breath
* factors that ease or aggravate the pain
* the pain's exact location. Ask him to point to the pain and record his response. For example, he may move his hand vaguely around his abdomen or point with one finger to his left chest.
* whether the pain radiates, and if so, where
* pain severity. Ask him to rate his pain on a pain intensity scale where 0 is no pain and 10 is the worst pain imaginable.
* whether he's ever had this pain before and if so, what treatment does or doesn't help relieve it.
Record his vital signs and perform a quick focused assessment of his body systems. Prepare him for an ECG and blood work. Document the time and name of the health care provider notified and provider's orders. Record your actions and the patient's responses. Include any patient education and emotional support you provided. Part of a good note might look like this:
12/9/07 0410-Pt. c/o sudden onset of sharp chest pain while sleeping. Points to center of chest over sternum. States, It feels like an elephant is sitting on my chest. Pain radiates to the L neck and both shoulders. Rates pain as 7 on a scale of 0 to 10. BP 90/62, P 112, RR 26. Fine bibasilar inspiratory crackles. Dr. Romano notified and orders received. Morphine 2 mg I.V. given. O2 at 4 L/minute started by NC. Continuous pulse oximetry started with O2 sat. 94%. Stat 12-lead ECG and serum cardiac biomarkers obtained. All procedures explained to pt. Reassured pt. that he's being closely monitored. Martha Wolcott, RN----------
Accurate, thorough documentation helps ensure that your patient's chest pain is correctly diagnosed and that he gets the care he needs.
Chart Smart: The A-to-Z Guide to Better Nursing Documentation, 2nd edition. Lippincott Williams & Wilkins, 2007.