From the Guidelines
An acute patient visit template should include chief complaint, history of present illness, past medical history, medications, allergies, review of systems, physical examination, assessment, and plan, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The initial assessment of patients presenting with acute chest pain is focused on the rapid identification of patients with immediately life-threatening conditions, such as ACS, acute aortic syndromes, and PE, as stated in the 2021 guideline 1. When evaluating a patient with acute chest pain, it is essential to consider the following key elements:
- Chief complaint: document the patient's primary concern and its duration
- History of present illness: detail the onset, location, duration, character, aggravating/alleviating factors, and associated symptoms
- Past medical history: include relevant medical conditions, such as previous myocardial infarction or coronary artery disease
- Medications: list current medications with dosages and allergies
- Review of systems: perform a focused review targeting the affected body systems
- Physical examination: conduct a physical examination to identify signs of immediate life-threatening instability
- Assessment: list differential diagnoses and working diagnosis
- Plan: outline specific treatments, including medication names, dosages, frequency, and duration, necessary diagnostic tests, follow-up instructions, and patient education The 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction also emphasizes the importance of rapid evaluation and management of patients with suspected ACS 1. The template should be customized based on the specialty and patient population, while maintaining these core elements, to ensure comprehensive documentation, facilitate clinical decision-making, and provide clear communication with other healthcare providers 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Template for an Acute Patient Visit
The template for an acute patient visit typically involves a systematic approach to assessment and treatment.
- The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is widely accepted and applicable in all clinical emergencies for immediate assessment and treatment 2.
- This approach helps healthcare professionals focus on the most life-threatening clinical problems and can improve outcomes by saving valuable time and improving team performance 2.
- The primary survey approach, which includes assessment of airway, breathing, circulation, and disability, is also recommended as the first element of patient assessment to ensure a proactive, evidence-based, patient safety approach 3.
- The ABCDE approach enables healthcare practitioners to identify and respond to life-threatening conditions in order of priority, and vital signs should be measured and recorded as part of this assessment 4.
Key Components of the Template
- Assessment of airway, breathing, circulation, disability, and exposure (ABCDE) 2, 4
- Measurement and recording of vital signs using a track and trigger tool 4
- Use of a structured communication tool to report assessment findings and escalate deteriorating patients 4
- Focus on identifying and responding to life-threatening conditions in order of priority 2, 4
Benefits of the Template
- Improves outcomes by saving valuable time and improving team performance 2
- Enables healthcare practitioners to identify and respond to life-threatening conditions in order of priority 4
- Enhances recognition of physiological abnormalities that signal deterioration 4
- Supports a proactive, evidence-based, patient safety approach to patient assessment 3