Name: Palpitations — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Most palpitations are benign, but a few signal a rhythm that can cause sudden death. The defensible chart documents the ECG interpretation (looking for the dangerous substrates), the red-flag history, and — for intermittent symptoms with a normal ECG — the monitoring plan rather than a flat "reassured."

01What's at stake

The ECG is the one near-universal test, because the dangerous causes hide there or in the history: ventricular tachycardia, pre-excitation (WPW), the channelopathies (long QT, Brugada), and structural disease (HOCM, ARVC). When the rhythm is intermittent and the ECG is normal, the safety net is appropriate ambulatory monitoring and follow-up.

02Can't-miss causes

Ventricular tachycardia — sustained/wide-complex; structural heart disease.
Pre-excitation (WPW) — delta wave; danger with AF (avoid AV-nodal blockers).
Channelopathies — long QT, Brugada pattern, short QT.
Structural disease — HOCM, arrhythmogenic RV cardiomyopathy.
Secondary causes — ACS, PE, electrolyte derangement, thyrotoxicosis, stimulants/drugs.

03History & exam red flags

Syncope or near-syncope with the palpitations? → malignant arrhythmia
Exertional onset, or known/suspected structural heart disease? → VT/HOCM
Family history of sudden death <50 or inherited arrhythmia? → channelopathy/cardiomyopathy
Sustained, rapid, irregular, or "pounding" with chest pain/dyspnea? → tachyarrhythmia / ACS / PE
Weight loss/tremor, stimulant use, vomiting/diuretics? → thyroid / drugs / electrolytes

Skip the typing

Work the case in the Palpitations Workup — it records the ECG, electrolytes, and TSH, and assembles an MDM that documents the dangerous rhythms and secondary causes were considered and the disposition reasoning.

04Testing & disposition

12-lead ECG on everyone — hunt for VT, a delta wave (WPW), prolonged QTc, Brugada pattern, LVH/HOCM features, ischemia, and ectopy; capture a rhythm strip if symptomatic.
Targeted tests — electrolytes, TSH, troponin if ACS suspected; hCG; tox when indicated.
Echo for suspected structural disease (often outpatient).
Intermittent symptoms, normal ECG → ambulatory monitoring (Holter/event/patch monitor) and cardiology follow-up; admit/monitor when red flags or a documented dangerous rhythm are present.

05What to document

▼ weak

"Palpitations, feels fine now, ECG normal sinus. Reassured, discharged."

▲ defensible

"Intermittent palpitations, no syncope, no exertional trigger, no family history of sudden death, no known heart disease. ECG: sinus, QTc 420, no delta wave, no Brugada pattern, no ischemia or LVH. Electrolytes and TSH normal. VT, WPW, channelopathy, structural disease, ACS, PE, and thyroid/electrolyte causes considered and felt unlikely. Discharged with an event/patch monitor and cardiology follow-up; return precautions for syncope, chest pain, or sustained palpitations."

06Where charts fail

No documented ECG interpretation (the one near-universal test).
Missing a delta wave (WPW), long QT, or Brugada pattern on the ECG.
Not eliciting the red flags — syncope, exertional onset, family history of sudden death.
"Reassured" for intermittent symptoms without arranging ambulatory monitoring.
Overlooking secondary causes (thyroid, electrolytes, stimulants, PE).

07Sources

Wexler RK, Pleister A, Raman SV. Outpatient approach to palpitations. Am Fam Physician. 2017;96(12):784-789.
Raviele A, Giada F, Bergfeldt L, et al. Management of patients with palpitations: a position paper from the European Heart Rhythm Association. Europace. 2011;13(7):920-934.
Probst MA, Mower WR, Kanzaria HK, et al. Analysis of emergency department visits for palpitations (NHAMCS). Am J Cardiol. 2014;113(10):1685-1690.
Giada F, Gulizia M, Francese M, et al. Recurrent unexplained palpitations: the role of prolonged monitoring (RUP study). J Am Coll Cardiol. 2007;49(19):1951-1956.

Palpitations: documentation that holds up