Patient Name: ___________________________
Date of Birth: ___________________________
Medicaid Record Number: _________________
CHAT: Chest Pain
History
How long ago did symptoms begin? Tell the story: ____________________________________
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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? ________________________________________
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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)
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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)