Chest Pain - American Health Care Association
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Patient Name: ___________________________ Date of Birth: ___________________________ Medicaid Record Number: _________________ CHAT: Chest Pain History How long ago did symptoms begin? Tell the story: ____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Other symptoms associated with the chest pain? □ Arm pain □ Jaw pain □ Dizziness □ Shortness of breath □ Nausea □ Sweating Has the patient had chest pain like this before? ________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Exam Current vital signs: ______________________________________________________________ Oxygen saturation: ______________________________________________________________ Are the lungs clear? _____________________________________________________________ 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) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ __ 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)
