According to interviews with 215 patients hospitalized for acute myocardial infarction (AMI), the most common symptoms of AMI were chest pain, fatigue, diaphoresis, weakness, shortness of breath, light-headedness, and nausea. But while chest pain and shortness of breath were documented in the medical chart 86% and 59% of the time, respectively, fatigue and weakness were recorded in only 4% and 7% of the charts, even though they were reported by patients 65% and 64% of the time, respectively. In addition, only 60% of the charts reported the time of symptom onset, and in 30% of these cases the charted time differed by more than an hour from the patient's own report. Such omissions and inaccuracies can have especially unfortunate consequences when one is determining a patient's eligibility for reperfusion therapy, which is time sensitive.

Clinicians need to keep in mind how important thorough and accurate documentation in the medical chart is to helping with patient assessment and symptom management. According to coauthor Julie Zerwic, "Health care providers are focusing in on selected, typical symptoms and ignoring others. It then becomes difficult to obtain an accurate account of the patient's experience and contributes to confusion over whether symptoms like fatigue are typical or atypical in AMI."

DeVon HA, et al. West J Nurs Res 2004;26(5):547-60.