John Smith · Male · DOB 1963-08-22
Unit responded emergent to a 62-year-old male complaining of chest pain radiating to the left arm with associated diaphoresis and mild shortness of breath. On arrival, patient was found seated on the front steps, pale and diaphoretic, clutching his chest. Patient reported the pain began approximately 30 minutes prior and rated it 8/10 in intensity. Patient was placed on oxygen via non-rebreather mask at 15 LPM with improvement in SpO2 from 94% to 97%. Vitals were obtained and documented; blood pressure was initially elevated at 162/98 with tachycardia at 108. Patient was assisted to the stretcher, loaded, and transported emergently to Mercy General Hospital without deterioration en route.
Initial
Final
A0429›No ALS criteria met → BLS
›Emergency: true → A0429
Inference: 21,366ms · Model: claude-sonnet-4-5
R07.9Chest pain, unspecified
PrimaryChest pain is the chief complaint and primary reason for the EMS call. While the presentation is highly suspicious for acute coronary syndrome (chest pain radiating to left arm, diaphoresis, age, elevated BP), no definitive diagnosis of MI or NSTEMI was documented in the EMS encounter. EMS medical coding requires coding only what is explicitly documented, not presumptive diagnoses.
R61Generalised hyperhidrosis (diaphoresis)
Diaphoresis was explicitly documented both in the chief complaint and in the assessment findings, representing an associated symptom that affected clinical presentation and care.
R06.00Dyspnea, unspecified
Shortness of breath was documented as part of the chief complaint and contributed to the clinical picture requiring oxygen administration.
R00.0Tachycardia, unspecified
Tachycardia was explicitly documented in the vital signs assessment and represents a significant clinical finding that affected patient assessment.
I10Essential (primary) hypertension
Elevated blood pressure was documented. While this could be reactive to acute pain/stress rather than chronic hypertension, the documentation of 'elevated' BP supports coding, though the etiology (chronic vs acute) is uncertain in this encounter.
A0429BLS emergency transport
No ALS criteria met → BLS → Emergency: true → A0429
A0425Ground mileage per statute mile
Loaded miles: 8
SHScene of accident/acute event to Hospital