Pmt form selection

AF Patient Management Tool
October 2013
PMT FORM SELECTION: Atrial Fibrillation
Legend: Elements in bold are required
Patient ID:
ARRIVAL AND ADMISSION INFORMATION
Internal Tracking ID:
Arrival Date and Time:
Admit Date:
Ο 1 Non-Health Care Facility Point of Origin Point of Origin
for Admission or
Ο 4 Transfer From a Hospital (Different Facility) Ο 5 Transfer from a Skilled Nursing Facility (SNF) or Intermediate Ο F Transfer from Hospice and is Under a Hospice Plan of Care or Enrolled in a Hospice Program Was patient admitted as inpatient? Ο Yes Ο No
If not admitted, was the patient observation status? DEMOGRAPHIC DATA
Date of Birth:
Hispanic Ethnicity: Ο Yes Ο No/UTD
 Mexican, Mexican American, Chicano/a  Another Hispanic, Latino or Spanish Payment Source:
Patient Postal Code:
MEDICAL HISTORY
Medical History
(Select all that
Labile INR (Unstable/high INRs or time in therapeutic range <60%)? Other risk factors
Ο No
Ο Unable to determine from the information available in the medical record
NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700
AF Patient Management Tool
October 2013
Prior Major Bleeding or Predisposition to Bleeding (bleeding diathesis, anemia, etc.)? Ο Yes
Ο No
Ο Unable to determine from the information available in the medical record
Procedures:
DIAGNOSIS
Ο Atrial Fibrillation
Ο Atrial Flutter
Atrial Arrhythmia Type:
Ο Permanent/long standing Persistent Atrial Fibrillation Was Atrial Fibrillation/Flutter the
patient’s primary diagnosis?
If no, what was the patient’s primary
diagnosis?
Were any of the following first detected on
this admission?
MEDICATIONS AT ADMISSION
 Patient on no meds prior to admission  ACE inhibitor  Aldosterone Antagonist  Alpha Blockers Medications Used Prior to
Admission
 rivaroxaban (Xarelto)  lepirudin (Refludan)  Other Anticoagulant EXAM/LABS AT ADMISSION
Presenting symptoms related  Exercise intolerance NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700
AF Patient Management Tool
October 2013
Heart Rate
Blood Pressure
_________ / _________ mmHg (systolic/diastolic)  Not documented Initial Presenting
Rhythm(s)
Select all that apply
If paced,
underlying Atrial
Rhythm
If paced, pacing
Resting Heart Rate (bpm)_____  Not Available QRS duration (ms) _______  Not Available Initial EKG findings:
PR interval (ms) _______  Not Available Platelet Count
________ mL/min (auto-calculated) Hemoglobin
___________ mg/dL
IN-HOSPITAL CARE
If A-Fib or A-Flutter Ablation selected above: Procedures this
hospitalization
 Cardioversion (check all that apply below)  CRT-D (cardiac resynchronization therapy w/ICD) EF – Quantitative
Obtained:
Ο W/in the last year Ο > 1 year ago Ο Not applicable Ο Normal or mild dysfunction Qualitative moderate/severe dysfunction NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700
AF Patient Management Tool
October 2013
CHADS2 reported?
If yes, total reported score
in medical record
CHADS2 Risk Factors
Prior stroke or TIA assessed Ο Yes Ο No Assessed
Medical reason(s) documented by a physician, nurse practitioner,
or physician assistant for not assessing risk factors
DISCHARGE INFORMATION
Discharge Date/Time
1 – Home 2 – Hospice – Home 3 – Hospice – Health Care Facility What was the patient’s discharge
disposition on the day of
discharge?
6 – Expired 7 – Left Against Medical Advise/AMA 8 – Not Documented or Unable to Determine (UTD) If Other Health Care Facility
Ο Inpatient Rehabilitation Facility (IRF) When is the earliest physician/APN/PA documentation
of comfort measures only?
BP-Supine
_________ / _________ mmHg (systolic/diastolic)  Not documented Heart Rate
Reason documented by a physician, nurse practitioner, or physician
assistant for discharging patient with heart rate >110 bpm?
Discharge Rhythm(s) (closest to discharge) NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700
AF Patient Management Tool
October 2013
Resting Heart Rate (bpm)_________  Not Available DISCHARGE MEDICATIONS
Prescribed?
Contraindicated?
Prescribed?
Contraindicated?
Prescribed?
Contraindicated?
Prescribed?
Medication:
Were Dofetilide or Sotalol newly initiated or dose
increased this hospitalization?
If yes, was a QT interval documented after 5 doses and
prior to discharge?
Contraindicated?
Prescribed?
Class: Medication:
Contraindicated?
Are there any
relative or absolute
contraindications to  Occupational risk
oral anticoagulant
therapy? (Check all
that apply)
Prescribed?
Contraindicated?
Prescribed?
Contraindicated?
Prescribed?
Contraindicated?
Prescribed?
Contraindicated?
NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700
AF Patient Management Tool
October 2013
Prescribed?
Contraindicated?
Prescribed?
Contraindicated?
Prescribed?
Contraindicated?
RISK INTERVENTIONS
Smoking Cessation Counseling Given
Ο Yes Ο No Ο Rhythm Control Strategy Planned Rhythm Control/Rate Control Strategy
Planned/Intended
Ο No Documentation of Strategy
 All were addressed (Check all yes)
Patient and/or caregiver received education
and/or resource materials regarding all of the
following:
Anticoagulation Therapy Education Given
PT/INR Planned Follow-up
Ο Home INR Monitoring Ο Anticoagulation Warfarin Clinic Who will be following patients INR?
Ο Managed by Physician associated with hospital Ο Managed by outside physician Ο Not documented Date of INR test planned post discharge:
____/____/______  Not documented
System Reason for no PT/INR Planned
Follow-up?
Ο Yes Ο No Ο Not Documented Ο Not Applicable Ο Yes Ο No Ο Not Documented Ο Not Applicable Ο Yes Ο No Ο Not Documented Ο Not Applicable Screening for obstructive sleep apnea (Berlin Ο Yes Ο No Ο Not Documented Ο Not Applicable Questionnaire) Referral for evaluation of obstructive sleep Ο Yes Ο No Ο Not Documented Ο Not Applicable Discharge medication instruction provided Ο Yes Ο No Ο Not Documented Ο Not Applicable OPTIONAL FIELDS
ICD-9 Principal Diagnosis Code
____________
NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700
AF Patient Management Tool
October 2013
___________ Date:___/___/_____  Date UTD 1. ________ Date:___/___/_____  Date UTD 2. ________ Date:___/___/_____  Date UTD 3. ________ Date:___/___/_____  Date UTD 4. ________ Date:___/___/_____  Date UTD 5. ________ Date:___/___/_____  Date UTD _____________
During this hospital stay, was the patient enrolled in a clinical trial in which patients with the same condition NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700
AF Patient Management Tool
October 2013
CHADS2 Calculation Tool (found on IN HOSPITAL Tab)
(Enabled if “No” is selected for CHADS2 Reported (in medical record)?)  Prior stroke or TIA  Age> 75  Hypertension  Diabetes  Congestive Heart Failure OTHER RISK SCORES
NOTE: CHADS2-VASc is an extension of the CHADS2 score. It contains additional risk categories and can be used as a
complimentary tool in the assessment of thromboembolic risk in atrial fibrillation patients. The AHA/ACC Guidelines
support the use of the CHADS2 score in assessment of thromboembolic risk and indication for anticoagulation therapy
is stratified using the CHADS2 score.
 Congestive Heart Failure  Hypertension (blood pressure consistently above 140/90 or treated with hypertension medication)  Age> 75  Diabetes  Prior stroke/TIA/Thromboembolism  Vascular Disease History (CAD, Prior MI, or PAD)  Female Gender
Adapted from a methodology used by the American College of Chest Physicians: Lip GY, Niewlatt R, Pisters R, Lane DA, Crijns HJ, et al.
Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach:
the euro heart survey on atrial fibrillation. CHEST 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 Sep 17.

DISCLAIMER: These tools (ATRIA and HAS-BLED) are presented for informational purposes only and not as an
endorsement of their use in clinical decision making. Many of the same risk factors for warfarin-related
hemorrhage are also risk factors for AF-associated ischemic stroke. The use of these tools as an exclusion for
anticoagulation is not part of AHA/ACC guideline-recommended care for patients with AF. Additionally, some of
the component elements in the HAS-BLED score, such as Labile INR and Prior Major Bleeding or Pre-Disposition
to Bleeding may be difficult to reliably ascertain from the information available in the health record. The HAS-
BLED score should be interpreted with this in mind.
 Anemia (Defined as Hemoglobin < 13 g/dL in men and < 12 g/dL in women)  Severe Renal Disease (defined as a GFR < 30ml/min or on dialysis)  History of Hypertension  Prior hemorrhage (intracranial, gastrointestinal, other hemorrhage) Adapted from a methodology used by the American College of Cardiology: Fang MC, Go AS, Chang Y, et al. A New Risk Scheme to Predict Warfarin-Associated Hemorrhage: The ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4):395-401. doi:10.1016/j.jacc.2011.03.03 NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700
AF Patient Management Tool
October 2013
 Hypertension History (uncontrolled, >160 mmHg systolic)  Renal Disease (Dialysis, transplant, Cr >2.6 mg/dL or >200 µmol/L)  Liver Disease (Chronic Hepatic Disease, including (e.g.) Cirrhosis, Bilirubin >2x Normal, AST/ALT/AP >3x Normal)  Stroke History  Prior Major Bleeding or Predisposition to Bleeding (bleeding diathesis, anemia, etc.)  Labile INR (Unstable/high INRs or time in therapeutic range <60%)  Age > 65  Medication Usage Predisposing to Bleeding (Antiplatelet agents, NSAIDs)  Alcohol Usage History (>20 units per week) Adapted from a methodology used by the American College of Chest Physicians: Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HM, Lip GH. A novel user-friendly score (has-bled) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the euro heart survey. Chest, 2010;138(5):1093-1100. NOT FOR USE WITHOUT PERMISSION. 2013 American Heart Association and Outcome Sciences, Inc. a Quintiles Company.
For questions, call 888-526-6700

Source: http://strokeondemand.net/idc/groups/heart-public/@wcm/@private/@hcm/@gwtg/documents/downloadable/ucm_457482.pdf