Patient Name: ___________________________
Date of Birth: ___________________________
Medicaid Record Number: _________________
CHAT: Dyspnea/Shortness of Breath
History
How long ago did this symptom start? Tell the story: ___________________________________
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Has the patient reported shortness of breath before in the last week? Tell the story:
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Other symptoms today:
□ Cough
□ Chest pain
□ Increased edema
Exam
Temperature, blood pressure, pulse oxygen saturation and amount of oxygen patient is currently
receiving? _____________________________________________________________________
______________________________________________________________________________
Are the patient’s lungs clear? ______________________________________________________
Is the patient in distress at rest because of problems breathing? ___________________________
Staff Name: _______________________________________________________ (RN/LPN) ___________
Reported to:
Name: _______________________________ (MD/NP/PA) Date: _______ Time: ______ am ___ pm ___
If to MD/NP/PA, communicated via: ______________ Phone _______________ In person _________
(This CHAT has been modified by AHCA. The original CHAT is a product of Duke University.)
Patient Name: ___________________________
Date of Birth: ___________________________
Medicaid Record Number: _________________
CHAT Progress Note
Progress Note (complete and place CHAT/progress note in medical record)
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__ Family or health care proxy notified
Return call/new orders from MD/NP/PA
Date___/___/___ Time___/___AM/PM
Signature________________________________RN/LPN
Date___/___/___ Time___/___AM/PM
(This CHAT has been modified by AHCA. The original CHAT is a product of Duke University)