CCM Heart Failure Note_Brief
Heart Failure Chronic Care Management Note History source: [checkbox name="Hx_Source" value="Patient|Nurse|Patient's power of attorney|Other"] Heart Failure Type: [select name="Heart_Failure_Type" value="Heart failure with reduced ejection fraction|Heart failure with presevered ejection fraction|Unknown"] [comment memo="HFrEF: EF ≤40% or “HF with reduced ejection fraction” (previously called “systolic HF”). HFpEF: EF ≥40% or “HF with preserved ejection fraction” (previously called “diastolic HF”)."] Date of last echocardiogram: [date name="echo_date" default="01/19/2022"] Left ventricular ejection fraction: [text name="EF" default="%"] Heart failure medications Beta-blocker [select name="beta_blocker" value="Bisoprolol|Carvedilol|Metoprolol succinate|Not on an evidence-based beta blocker"] Current dose: [text name="beta_blocker_dose" default="mg daily"] [comment memo="These medications are recommended for all patients with HFrEF. They help the heart to pump better over time. Side effects include fatigue, low heart rate, and low blood pressure."] ACE/ARB/ARNI [select name="ACE_ARB" value="Captopril|Enalapril|Lisinopril|Ramipril|Candesartan|Losartan|Valsartan|Sacubitril/valsartan|Not on an evidence-based ACE, ARB or ARNI"] Current dose: [text name="ACEARB_dose" default="mg daily"] [comment memo="These medications are recommended for all patients with HFrEF. They relax blood vessles, making it easier for the heart to pump. Side effects include cough, low blood pressure, and elevated potassium levels. Electrolytes (blood work) should be monitored closely after starting these medications."] Diuretic [select name="Diuretic" value="Furosemide (Lasix)|Bumetanide (Bumex)|Torsemide|Not on a diuretic"] Current dose: [text name="Diuretic_dose" default="mg daily"] [comment memo="These medicines help to pull off extra fluid, which can help with breathing, exercise tolerance, and swelling. The will cause frequent urination. It's best to take these medicines soon after waking up. If the patient has to leave the house in the morning (e.g., for church), it's OK to wait and take the medicine when they get home. An additional dose can be given after 4 hours if the patient is taking the medication more than once per day. "] Statin [select name="Statin" value="Atorvastatin (Lipitor)|Simvastatin |Rosuvastatin (Crestor)|Lovastatin|Not on a statin"] Current dose: [text name="Statin_dose" default="mg daily"] [comment memo="These medicines help prevent heart attacks and strokes. While it is generally recommended to take the medicine at bedtime, if the patient often forgets, it's OK to take it earlier in the day with other medications. These medicines can cause some muscle cramping. The patient should discuss this side effect with their provider rather than just stopping the medicine."] Aspirin [select name="ASA" value="Aspirin 81mg|Aspirin 325mg|Not on aspirin"] [comment memo="These medicines help thin the blood to prevent heart attacks and strokes. These medicines can make the patient bruise and bleed more easily. The patient should discuss this side effect with their provider rather than just stopping the medicine."] Most recent heart rate: [text name="HR" default="bpm"] Most recent blood pressure: [text name="BP" default="/"] Date of last basic metabolic panel (BMP):[date name="BMP_date" default="01/20/2022"] Potassium: [text name="K" default="K"] Creatinine:[text name="Cr" default="Cr"] eGFR:[text name="GFR" default="GFR"][link url="https://www.kidney.org/professionals/kdoqi/gfr_calculator" memo="GFR calculator"] [comment memo="It is important to monitor these labs often as medications to treat heart failure can affect the kidney and electrolytes. The labs should be checked about every 3 months or a week or two after adjustments in some medications."] Date of last B-type natriuretic peptide (BNP):[date name="BNP_date" default="01/20/2022"] BNP: [text name="BNP" default="BNP"] [comment memo="BNP can be helpful to identify flare-ups or exacerbations of heart failure. Knowing the patient's usual BNP can help providers know if the patient's condition is worse."] Patient/caregiver assessment of heart failure status: [comment memo="Which best describes the patient's ability to do physical activity at this time?"] [select name="NYHA_Class" value="NYHA Class 1 - Patient can perform all physical activity without getting short of breath or tired, or having palpitations.|NYHA Class 2 - Patient gets short of breath or tired, or has palpitations when performing more strenuous activities. For example, walking on steep inclines or walking up several flights of steps.|NYHA Class 3 - Patient gets short of breath or tired, or has palpitations when performing day-to-day activities. For example, walking on the flat.|NYHA Class 4 - Patient feels breathless at rest, and is mostly housebound. Patient is unable to carry out any physical activity without getting short of breath or tired, or having palpitations.- NYHA Class 4"] Self-Care Habits Do you have a scale that you can use to weigh the patient? [select name="scale" value="Yes|No"] How often does the patient have their weight monitored? [select name="weight" value="Never|Monthly|Weekly|Some days|Most days"] [comment memo="Tell patient that daily weights are important to self-monitor for fluid retention. Weight should be every morning, after first void, before eating or drinking anything with the same amount of clothing on."] How often does the patient eat a low salt diet? [select name="salt" value="Never|Some days|Most days"] [comment memo="Explain the Salty Six Foods - processed meats, pizza and pasta sauces, bread, soup, salt seasonings, burritos and tacos. Explain that patients should not add salt at the table and if food tastes salty, ask for another option."] How often does the patient miss a dose of their medication? [select name="miss_meds" value="Never|Some days|Most days"] How confident do you feel that you can monitor your heart failure/the patient's heart failure? [select name="monitor" value="Not confident|Somewhat confident|Extremely confident"] How confident do you feel that you can follow the treatment plan the patient has been given? [select name="rx_plan" value="Not confident|Somewhat confident|Extremely confident"] The following message will be sent to provider: Heart failure treatment plan reviewed today. Please consider if the following may be appropriate for your patient: [checklist name="Plan" value="Patient may benefit from an echocardiogram.|Patient may benefit from a basic metabolic panel.|Patient may benefit from the addition of or increased dose of an ACE/ARB/ARNI (goal dose is 20-40mg daily of lisinopril, 10-20mg twice daily of enalapril, 10mg daily of ramipril, 150mg daily of losartan, 160mg twice daily of valsartan, or 97/103mg of sacubitril/valsartan).|Patient may benefit from the addition or or increased dose of a beta-blocker (10mg daily of bisoprolol, 25 mg twice daily for weight <85 kg and 50 mg twice daily for weight ≥85 kg of carvedilol, or 200mg daily of metoprolol succinate)."] Patient's goals at this time: [checklist name="SMART_Goals" value="Patient will begin weighing themself daily and record these weights for the provider's next visit.|Patient will begin monitoring the sodium in their diet with a goal of less than 2 gram/day.|Patient will decrease their intake of the following food(s):|Patient will be sent information about heart failure.|Patient will take their diuretic as scheduled.|Patient will take their ACE/ARB/ARNI as scheduled.|Patient will take their beta-blocker as scheduled."]
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Sandbox Metrics: Structured Data Index 0.63, 42 form elements, 178 boilerplate words, 11 text boxes, 3 dates, 1 checkboxes, 2 check lists, 13 drop downs, 1 links, 11 comments, 42 total clicks
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