Chest Pain or Acute Coronary Syndrome Evaluation Note

Date/Time: [Date and time of encounter]

Location/Level of Care: [ED / Observation Unit / Inpatient Unit]

Author: [Name, role, service]

Data Sources: [Patient / EMS / Family / Prior records] (Note reliability limitations if history is incomplete)

ACS Evaluation Summary

Chest Pain Classification: [cardiac / possible cardiac / noncardiac] (Brief rationale; avoid "typical/atypical" terminology; omit if not applicable)

Hemodynamic Status: [Stable / Unstable] (Specify abnormalities if unstable)

High-Risk Features: [Present / Absent] (If present, specify: ongoing pain, dynamic ST changes, hemodynamic instability, heart failure signs)

ECG Summary: [ischemic / nonischemic] | STEMI concerns: [yes / no] (Include key findings and whether serial ECGs show dynamic changes)

Troponin Strategy: Assay: [hs-cTnI / hs-cTnT / conventional cTn] | Pathway: [0/1-hr / 0/2-hr / 0/3-hr / other] | Values: [Value @ time, Value @ time] | Interpretation: [rule-out / observe / rule-in] (Mark pending results with expected time)

Risk Stratification: [HEART / EDACS / TIMI / structured clinical rationale] Score: [#] (Include component breakdown if using a tool; otherwise provide brief structured rationale for risk category; omit if not used)

Working Diagnosis: [Working diagnosis]

Disposition: [discharge / observation / admission / cath lab] – [One-sentence rationale] (Omit if pending decision)

History of Present Illness

[Patient's stated concern], followed by narrative of chest pain characteristics: [Onset date/time with certainty], [Duration], [Course: improving / worsening / intermittent], [Quality: pressure / tightness / burning / sharp / pleuritic], [Location and radiation], [Provoking and relieving factors including exertion, rest, nitroglycerin response], [Associated symptoms: dyspnea, diaphoresis, nausea, palpitations, syncope], [Activity at onset], [Pre-arrival treatments and response], [Prior similar episodes and comparison to known angina or prior MI]. (Document onset time as unknown with explanation if uncertain)

Red-flag screen: Aortic dissection [positives/negatives for: tearing pain, pulse deficit, neurologic symptoms, severe hypertension]; PE [positives/negatives for: pleuritic pain, hemoptysis, leg swelling, immobility, cancer]; Pericarditis [positives/negatives for: positional pain, viral prodrome]; Pneumothorax [positives/negatives for: sudden pleuritic pain, unilateral breath sounds].

Risk factors: [Known CAD with prior interventions], [Heart failure], [Diabetes], [Hypertension], [Hyperlipidemia], [Tobacco], [CKD], [Cocaine/stimulant use], [Family history of premature CAD]. (Include only items explicitly stated; document key unknowns affecting risk interpretation)

Pertinent History and Medications

• Cardiovascular history: [Known CAD, prior MI, PCI/CABG with dates, prior catheterization findings]
• Recent cardiac testing: [Stress test / Echo / CCTA / Cath with dates and key results] (Include only if available)
• Baseline troponin pattern: [Known chronic elevation / prior baseline values / unknown]
• Bleeding risk factors: [History of bleeding, thrombocytopenia, recent surgery, liver disease] (Include only if anticoagulation considered)
• Current relevant medications: [Antiplatelets, anticoagulants, beta-blocker, statin, nitrates, PDE-5 inhibitors] (Note timing of last dose if relevant)
• Allergies: [Aspirin, contrast, other cardiovascular-relevant allergies with reaction type]

Physical Exam

• Vital signs: [Current values with trends or worst values; oxygen requirement]
• General: [Comfortable / distressed / diaphoretic / toxic-appearing]
• Cardiovascular: [Rate/rhythm], [Murmurs/rubs/gallops], [Pulses/perfusion] (Note if murmur is new)
• Respiratory: [Work of breathing], [Breath sound symmetry], [Focal findings]
• Chest wall: [Reproducible tenderness present / absent]
• Volume status: [JVP], [Peripheral edema], [Rales]
• Neurologic: [Focal deficits, mental status, pulse symmetry] (Include only if dissection or syncope concern)

Objective Data

ECG: [Time(s) obtained]; [Comparison to prior]; [Clinician interpretation: ST changes, T-wave inversions, new LBBB, paced rhythm]; Serial ECGs: [dynamic changes present / absent with description].

Cardiac Biomarkers: Assay: [hs-cTnI / hs-cTnT / conventional cTn]; Values: [Value @ time, Value @ time]; Delta: [rise / fall / no significant change]; Interpretation: [normal / elevated with acute rise-fall pattern / chronic elevation]; [Reference prior baseline if known].

Labs: [Renal function], [CBC], [Glucose], [Other labs impacting management]. (Omit nonessential labs)

Imaging: [CXR findings], [Echo findings if performed: wall motion, effusion], [CCTA or stress test results if obtained].

External Records: [Prior ECGs, stress tests, echocardiograms, catheterization reports with key findings]. (Include only if reviewed)

Assessment and Medical Decision Making

Chest Pain – ACS Evaluation

[Clinical synthesis integrating symptoms, risk factors, ECG interpretation, troponin results and delta, and response to treatment. State why ACS is more or less likely. Document whether alternative life-threatening diagnoses have been reasonably excluded or require further workup.]

Risk Stratification: [HEART / EDACS / TIMI] Score: [#]; Components: [History, ECG, Age, Risk factors, Troponin]. Risk category: [low / intermediate / high] with operational implication for disposition and testing. (If using structured narrative instead, list inputs and risk conclusion; if deviating from tool guidance, state reason)

Troponin/MI Classification: [No myocardial injury / Acute myocardial injury / Chronic myocardial injury]; Evidence of ischemia: [present / absent]; If MI diagnosed: [Type 1 / Type 2] with brief rationale. (If insufficient evidence for MI, state "acute myocardial injury, etiology under evaluation")

Plan

Monitoring: Telemetry: [yes / no]; Vital signs: [frequency]; Oxygen: [strategy and targets]; Repeat ECG: [timing and triggers for earlier repeat].

Troponin Strategy: Algorithm: [0/1-hr / 0/2-hr / 0/3-hr / other]; Next draw: [time]; Delta threshold: [criteria]. (Note timing adjustments if onset is early or uncertain)

Additional Testing: [No urgent testing with rationale / Observation with noninvasive testing type and timing / Urgent invasive evaluation]. (Specify test modality and planned timing)

Therapeutics: [Aspirin given/withheld with rationale], [Nitrates given/withheld; note PDE-5 inhibitor status], [Beta-blocker], [Anticoagulation agent and dose if used], [High-intensity statin], [Analgesia]. (Note contraindications)

Alternative Diagnosis Workup: [PE rule-out, aortic dissection imaging, other targeted evaluations with rationale]. (Include only if pursuing alternative diagnoses)

Consults: [Cardiology / Hospitalist / ICU] – [Timing and key recommendations]. (Include only if consulted)

Disposition: [discharge / observation / admission / cath lab] – [Rationale linking risk category, objective findings, and planned management].

Follow-up and Return Precautions

(Include only if patient is being discharged)

• Follow-up: [Timeframe] with [provider type]
• Outpatient testing: [Planned test and timing] (Include only if applicable)
• Medication changes: [New starts, changes, discontinuations with rationale]
• Return precautions: Worsening or recurrent chest pain, dyspnea, syncope, palpitations, new neurologic symptoms