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 template should begin by documenting the patient's primary concern and its duration, followed by a detailed history of present illness with onset, location, duration, character, aggravating/alleviating factors, and associated symptoms.
- Relevant past medical history, current medications with dosages, and allergies should be included.
- A focused review of systems and physical examination targeting the affected body systems should be performed.
- In the assessment section, differential diagnoses and working diagnosis should be listed.
- The plan should outline specific treatments, including medication names, dosages, frequency, and duration, necessary diagnostic tests, follow-up instructions, and patient education. This structured approach ensures comprehensive documentation, facilitates clinical decision-making, supports billing requirements, and promotes continuity of care between providers, as supported by 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 1. Customization of the template based on specialty and patient population is essential while maintaining these essential elements, and healthcare providers should be informed about signs and symptoms of acute coronary syndrome (ACS) over the telephone or in person by the patient or family members, and advise patients with possible accelerating angina or angina at rest that an evaluation cannot be performed solely via the telephone 1.
From the Research
Template for an Acute Patient Visit
The template for an acute patient visit is based on the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach, which is widely accepted by experts in emergency medicine 2, 3. This approach is applicable in all clinical emergencies for immediate assessment and treatment.
Key Components of the ABCDE Approach
- Airway: Assessment of the patient's airway to ensure it is patent and protected 2, 3
- Breathing: Evaluation of the patient's breathing to ensure it is adequate and effective 2, 3
- Circulation: Assessment of the patient's circulation to ensure it is adequate and effective 2, 3
- Disability: Evaluation of the patient's neurological status to ensure it is adequate and effective 2, 3
- Exposure: Exposure of the patient to ensure a thorough assessment of their condition 2, 3
Implementation of the ABCDE Approach
The ABCDE approach should be used as the first element of patient assessment in every patient encounter as a patient safety strategy 4. This approach provides nurses with a consistent, evidence-based, and sequenced approach to patient assessment in every clinical setting. The use of a track and trigger tool to record vital signs and a structured communication tool to report ABCDE assessment findings can enhance recognition of physiological abnormalities that signal deterioration and optimize communication and escalation of deteriorating patients 5.
Benefits of the ABCDE Approach
The ABCDE approach has several benefits, including:
- Improves outcomes by helping healthcare professionals focus on the most life-threatening clinical problems 2, 3
- Saves valuable time and improves team performance in an acute setting 2, 3
- Provides a systematic approach to patient assessment, enabling healthcare practitioners to identify and respond to life-threatening conditions in order of priority 5