O80 - Encounter for full-term uncomplicated delivery

Clinical Definition

Chest pain (unspecified) is a discomfort or painful sensation located anywhere in the anterior thoracic region between the neck and upper abdomen, without a determined specific cause after evaluation.

Documentation Requirements

• Exact location of pain:

  • Anterior chest wall

  • Left or right side

  • Substernal region

  • Multiple sites in thorax

• Timing and pattern:

  • Acute vs chronic

  • Intermittent vs constant

• Associated symptoms

• Ruled out conditions:

  • Cardiac origin

  • Respiratory origin

  • Musculoskeletal origin

• Severity (mild/moderate/severe)

• Duration of symptoms

Common Synonyms

• Thoracic pain

• Chest discomfort

• Chest tightness

• Chest pressure

• "Heavy feeling in chest"

• "Elephant sitting on chest"

Coding Conflicts

Excludes1:

• Angina pectoris (I20.-)

• Pain in breast (N64.4)

• Epidemic myalgia (B33.0)

Excludes2:

• Precordial pain (R07.2)

• Pain in throat (R07.0)

Scribing.io Automation

The AI scribe automatically:

1. Identifies chest pain descriptions in patient narratives

2. Tags anatomical locations mentioned

3. Captures timing patterns

4. Flags ruled-out conditions

5. Records severity descriptors

6. Notes associated symptoms

7. Highlights any cardiac-related terminology for physician review

Important: The AI distinguishes between general chest pain and specific causes, ensuring proper code assignment and avoiding excluded conditions.