Acute Myocardial Infarction (AMI) [Documentation Suggestions]

Acute Myocardial Infarction (AMI)

Documentation Suggestions
  • Describe clinical signs and symptoms (e.g., crescendo angina, fourth heart sound, left ventricular failure, pain radiating to left arm, etc.).
  • Document work-up (e.g., serum cardiac markers such as Troponin T, EKG, electrolytes, etc.).
  • Document treatment (e.g., beta-blockers, ACE inhibitors, ASA, digitalis, O2, morphine sulfate, nitrates, reperfusion therapy, etc.).
  • Note any contraindications to conventional drug therapies (e.g., ASA not used due to recent stomach ulcer).
  • Note approximate age of infarction (if not newly diagnosed).

Additional notes:

 

 


Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: http://www.hce.org/medicare/mcareHPMP.html 7/7/03)