Heart Failure CCM Note_Comprehensive

Heart Failure Chronic Care Management Note

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."]

Aldosterone Antagonist
[select name="Aldosterone" value="Eplerenone|Spironolactone|Not on an aldosterone antagonist"]
Current dose: [text name="AA_dose" default="mg daily"]
[comment memo="These medications are recommended for many patients with HFrEF.  They block sodium and water reabsorption, helping prevent further damage to the heart.  Side effects include elevated potassium levels.  Electrolytes (blood work) should be monitored closely after starting these medications."]

SGLT2 Inhibitor
[select name="SGLT2" value="Dapagliflozin|Empagliflozin|Not on an evidence-based SGLT2 inhbibitor"]
Current dose: [text name="SGLT2_dose" default="mg daily"]
[comment memo="These medications are recommended for many patients with HFrEF.  They increase the body's excretion of sugar and promote healing of the heart.  Side effects include yeast infections and urinary tract infections."]

Vasodilator
[select name="Vasodilator" value="Hydralazine|Isosorbide dinitrate|Not on a vasodilator"]
Current dose: [text name="Vasodilator_dose" default="mg daily"]
[comment memo="These medications are recommended for some patients with HFrEF.  They relax blood vessles, making it easier for the heart to pump.  Side effects include low blood pressure and headaches."]

Ivabradine
[select name="Ivabradine" value="Ivabradine (Corlanor)|Not on ivabradine"]

Diuretic
[select name="Diuretic" value="Furosemide (Lasix)|Bumetanide (Bumex)|Torsemide|Not on a diuretic"]
Current dose: [text name="Diuretic_dose" default="mg daily"]

Statin
[select name="Statin" value="Atorvastatin (Lipitor)|Simvastatin |Rosuvastatin (Crestor)|Lovastatin|Not on a statin"]
Current dose: [text name="Statin_dose" default="mg daily"]

Aspirin
[select name="ASA" value="Aspirin 81mg|Aspirin 325mg|Not on aspirin"]

Patient is currently taking the following medications that can have an adverse effect on heart failure:
[checkbox name="Adverse_Meds" value="Diltiazem|Verapamil|Nifedipine|Doxazosin|Pioglitazone|Rosiglitazone|Saxagliptin|Pregabalin|Citalopram|Ibuprofen|Naproxen|Sotalol|Oxaprozin|Diclofenac|Celecoxib"]

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"]

Patient/caregiver assessment of heart failure status:
[comment memo="Which best describes your 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 at home that you can use to	weigh yourself?
[select name="scale" value="Yes|No"]
How often do you monitor your weight?
[select name="weight" value="Never|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 do you 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"]
How often do you miss a dose of your 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 an ACE/ARB/ARNI.|Patient may benefit from a beta-blocker.|Patient may benefit from statin therapy.|Patient may benefit from aspirin therapy."]

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:|Patient will be sent information about heart failure.|Patient will take their diuretic daily.|Patient will take their ACE/ARB/ARNI as scheduled.|Patient will take their beta-blocker as scheduled."]