Examine Heart

It goes without saying that a patient with chest pain requires immediate clinical attention due to the seriousness of the possible causes. Because of this, the evaluation from the first point of contact is critical for rapid treatment and resolution of symptoms, and is the appropriate place to begin a record review, regardless if that first point of contact is the emergency department directly or via a medical office or clinic.

The provider uses information gathered from the history, physical examination, test results/reports, and ancillary care department reports to formulate a diagnosis and develop a treatment plan. This gathered information is collectively called clinical indicators.

Clinical indicators are the clues the provider uses to assist in determining why the patient is experiencing their particular signs and symptoms. They are the same clues that the CDI professional uses to ensure validate documented diagnoses/conditions, confirm that the documentation precisely describes the patient’s health status, and also used when seeking documentation clarification.

Using clinical indicators, the provider will first channel efforts to the likely cause(s) of the patient’s chest pain. Some of these causes could be:

  • Myocardial infarction/angina/coronary disease
  • Musculoskeletal – such as, costochondritis (Tietze’s syndrome), bruised or broken ribs, fibromyalgia
  • Pleurisy/myocarditis
  • Atelectasis
  • Pneumothorax
  • Shingles
  • Pneumonia or chronic obstruction pulmonary disease (COPD) exacerbation
  • Pulmonary embolus
  • Pulmonary hypertension
  • Panic attack, psychological stress, ventricular irritability (neurasthenia)
  • Aortic dissection
  • Reflux esophagitis/gastroesophageal reflux disease/dysphagia/esophageal rupture/gastric/duodenal ulcer/colitis
  • Acute chest syndrome of sickle-cell disease
  • Referred abdominal pain from gallbladder, pancreas

It’s important to note that while any of these diagnoses may be considered by the provider, they might not be documented in the medical record until more information is gathered from testing. However, in order to understand the thought processes, it is helpful both to the healthcare team concurrently, and to the vast number of those who review the record retrospectively, if the provider documents those diagnoses under consideration as ‘possible…’, ‘likely…’, or ‘suspected…’, etc. In addition to information amassed from the history, findings garnered from the physical examination can also provide clues. For example:

  • Rash > suggests shingles
  • Carotid bruit or heart murmur > suggests cardiac issue
  • Chest palpation > suggests musculoskeletal issue
  • Abnormal breath sounds > suggests lung issue
  • Friction rubs > suggests lung or pleural issue
  • Abnormal heart sounds or jugular venous distention > suggests pericardial, cardiac issue
  • Jugular venous distention > suggests pericardial, cardiac issue
  • Abdominal palpation > for masses or GI pain

Looking at the ‘reason for test’ provides a window into thought processes and when aligned with other clinical indicators can begin to fit the pieces of the puzzle together. The days when a full spectrum of tests is performed have vanished; instead, the provider orders only those tests/evaluations where there is strong suspicion of one or a few diagnoses, such as the following with chest pain:

  • Troponin/creatine phosphokinase (CPK)s > rule out cardiac
  • Erythrocyte sedimentation rate (ESR) or C-reactive protein > rule out myocarditis
  • Serum lipase > rule out pancreas
  • WBC > rule out infection
  • Arterial blood gas (ABG) > rule out lung disorder
  • Esophagoscopy with contrast > esophageal rupture
  • Esophagoscopy/esophagogastroduodenoscopy/colonoscopy/ileoscopy, with or without biopsy; H. pylori > rule out GI source
  • Ultrasound > rule out gallbladder disorder
  • Barium swallow > rule out esophageal motility disorder
  • Cardiac angiogram; with or without ergonovine provocation test > rule out coronary disease/spasm
  • Ventilation-perfusion scan > rule out lung or embolism
  • Pulmonary angiogram or peripheral arteriogram > rule out embolism, deep vein thrombosis (DVT)
  • Stress test > rule out cardiac disorder

Lastly, but certainly not least, the treatment can provide additional clinical indicators for use with clinical validation, and/or in the formation of a clarification query. Some of the treatment seen with an admitting diagnosis of chest pain might include:

  • Aspirin, beta blockers, nitroglycerin > cardiovascular
  • Acid blockers, antacids > gastrointestinal
  • Ice or warm compresses > musculoskeletal pain
  • Thoracentesis > pleurisy, effusion
  • Chest tube > pneumothorax
  • Antiviral meds > shingles
  • Antibiotics > infection
  • Anticoagulation or thrombolytic therapy > embolism, thrombosis

Using clinical indicators to validate documented diagnoses and conditions, confirm medical necessity, and/or assist in formulating a query to clarify a more appropriate diagnosis than a symptom not only helps the CDI professional, but also assists the provider in documenting a complete, precise encounter which will aid the coding professional after the hospital visit, and will ultimately benefit the patient.

Respectfully submitted,
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Director of Education, MedPartners



Optum360. 2016. Guide to clinical validation, documentation and coding: Validating code assignments with clinical documentation. 2017. Optum360 LLC.

Pinson, R.D. & Tang, C.L. 2016. CDI Pocket Guide. 2017. HCPro.


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