WIP – TVAMC PharmD Anticoagulation Clinic DOAC Note

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SUBJECTIVE
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CC/PURPOSE 
Patient is a(n) [text name="age" default=""] y/o [select name="sex" value="male|female"] who was flagged on the DOAC dashboard [select name="purpose" value="for potential non-adherence|as needing education|other"] [conditional field="purpose" condition="(purpose).is('other')"][text name="purpose-other" default=""][/conditional] 

HPI
[textarea name="hpi" default=""]

Relevant documented active problems:
[textarea name="problist" default="Problem list"]
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Drug: [select name="anticoagulant" value="apixaban|dabigatran|rivaroxaban"]
Dosing: [conditional field="anticoagulant" condition="(anticoagulant).is('apixaban')"][select name="apixabandose" value="5mg PO BID|2.5mg PO BID|10mg PO BID"] [/conditional] [conditional field="anticoagulant" condition="(anticoagulant).is('rivaroxaban')"] [select name="rivaroxabandose" value="20mg PO daily|15mg PO daily|10mg PO daily|2.5mg PO BID"][/conditional] [conditional field="anticoagulant" condition="(anticoagulant).is('dabigatran')"][select name="dabigatrandose" value="150mg PO BID|110mg PO BID|75mg PO BID"][/conditional]
Indication: [select name="indication" value="atrial fibrillation|VTE|other"]
Duration: [select name="duration" value="indefinite|3 months|6 months|to be determined|other"] [conditional field="duration" condition="(duration).is('other')"][text name="variable_1" default=""][/conditional]
Last filled date: [date name="lfdate" default=""]
Days' supply: [text name="dayssupply" default=""]
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OBJECTIVE
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VITALS 
[textarea name="vitals" default="Height & Weight"]

LABS
    [textarea name="labs" default="SCr, ALT, AST, Plt, Hgb, Hct"]
    [comment memo="CHA2DS2-VASc will automatically pop-up if indication is a fib"]
    
[conditional field="indication" condition="(indication).is('atrial fibrillation')"]CHA2DS2-VASc Scoring:
[checkbox name="chadsvasc" value="(1) Chronic heart failure|(1) Hypertension|(2) Age ≥ 75|(1) Diagnosis of diabetes mellitus|(2) History of stroke, TIA, VTE|(2) History/current vascular diease including MI, PAD, or cerebral ischemia|(1) Age 65 - 74 y/o"] [conditional field="sex" condition="(sex).is('female')"]& (1) Sex - female[/conditional]
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Total score: [text name="chadsvascscore" default=""] which indicates [select name="vterisk" value="|low|low-moderate|moderate-high"] risk of thromboembolic complications[/conditional]  
    
[comment memo="will turn this into an interpretative calc at some point"]   
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MEDICATION PROFILE [comment memo="Import this section from 'Shared Templates' menu"]
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ALLERGIES/ADRs: [text name="allergies" default=""]

MEDICATION LIST:
[textarea name="medlist" default=""]

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ASSESSMENT      [+] = Yes / True    [-] = No / False 
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RENAL & LIVER FUNCTION:
[checklist name="renal_hepatic" value="SCr is WNL and is stable / representative of baseline|Liver enzymes are WNL|Patient has NO history of cirrhosis, hepatitis, or any other liver diseases"]

SAEFTY:
[checklist name="bleeding" value="Patient does NOT have a history of bleeding events|Platelets, hemoglobin, hematocrit are WNL|Patient DENIES signs / symptoms of bleeding currently"]

[comment memo="I will be adding to the DDI section later. I'll include what the expected interaction is (PD vs PK and what the mechanism is) and what the guidance for adjustments is."]
DRUG-DRUG INTERACTIONS: 
[checkbox name="ddis" value="SSRIs/TCAs/SNRIs|Aspirin|Clopidogrel, prasugrel, ticagrelor, cangrelor, ticlopidine|NSAIDs|Strong 3A4 inhibitors (adagrasib; atazanavir; ceritinib; darunavir; idelalisib; indinavir; lonafarnib; lopinavir; miFEPRIStone; nefazodone; nelfinavir; ombitasvir, paritaprevir, ritonavir, and dasabuvir; saquinavir; selithromycin; tucatinib; voriconazole)|Moderate 3A4 inhibitors (aprepitant; berotralstat; conivaptan; crizotinib; dilTIAZem; duvelisib; fedratinib; fluconazole; fosamprenavir; fosnetupitant; grapefruit juice; imatinib; lefamulin; lenacapavir; letermovir; netupitant; nilotinib; ribociclib; schisandra)|Strong 3A4 inducers (enzalutamide, lumacaftor, ivacaftor, mitotane, phenobarbital, primidone)|Strong dual 3A4 & P-gp inhibitors (clarithromycin, cobicistat, itraconazole, ketoconazole systemic, ritonavir, ombitasvir, paritaprevir, posaconazole, tucatinib)|Carbamazepine, rifampin, phenytoin|Valproate / valproic acid / sodium valproate / divalproex|Levetiracetam|No significant drug-drug interactions identified"]

DOSING APPROPRIATENESS:
[select name="doseappro" value="Dosing is appropriate given the patient's age, height, weight, indication for anticoagulation, bleeding risk, comorbidities, renal function, liver function, and concomitant drugs.|Dosing of current anticoagulant may be inappropriate due to"][conditional field="doseappro" condition="(doseappro).is('Dosing of current anticoagulant may be inappropriate due to')"] [text name="doseinappro" default=""] [/conditional]
 
RISK VS. BENEFIT:
Given the patient's indication for anticoagulation therapy and safety profile (as assessed by history of bleeding events, platelets, hemoglobin, hematocrit, and signs or symptoms of bleeding):
[select name="riskvbenefits" value="The benefits of continuing current anticoagulant likely outweigh the risks|The risks of continuing current anticoagulant likely outweigh the benefits"]

ADHERENCE: 
[select name="adherence" value="Adequate adherence to anticoagulant is suspected.|Adherence to anticoagulant is suboptimal."] 
[comment memo="My conditionals are often not working, so if you select that adherence is suboptimal, you should now see the word 'test'."] [conditional field="adherence" condition="(adherece).is('Adherence to anticoagulant is suboptimal.')"] test [/conditional]
[conditional field="adherence1" condition="(adherence).is('Adherence to anticoagulant is suboptimal.')"] Potential barriers to adherence include: [checkbox name="adherencechk" value="Forgetfulness|Pill burden|Instructions not clear|No perceived benefit|Worried about side effects|Other"] [text name="other1" default=""] [/conditional]
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PLAN
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[select name="doacplan" value="Continue|Continue & refill|Continue & renew|Discontinue|Change"] [var name="anticoagulant"] [conditional field="doacplan" condition="(doacplan).is('Change')"] from [text name="change" default=""] to [text name="change1" default=""] [/conditional] 

[comment memo="trying to find a way to recall several variables at once - ie doac name, dose/sig, etc; however, something is broken and cannot recall multiple variable at once; will investigate further"]
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EDUCATION
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Regarding the patient's anticoagulation therapy, the following points (at aminimum) were addressed:
  - Medication name, identification, proper storage, and dosing schedule
  - Indication for therapy
  - Signs and symptoms of bleeding and thromboembolic events
  - Adherence/refill process
  - Monitoring requirements
  - Interacting medications
  - Planned invasive procedures
  - Contact information for the Anticoagulation Service
 
For ongoing monitoring, a population-based approach will be used to ensure
safety, adherence to therapy, and appropriateness of prescribing.  Periodic risk/benefit assessments will be performed as necessary.
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SUBJECTIVE
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CC/PURPOSE
Patient is a(n) y/o who was flagged on the DOAC dashboard

HPI


Relevant documented active problems:

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Drug:
Dosing:
Indication:
Duration:
Last filled date:
Days' supply:
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OBJECTIVE
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VITALS


LABS

CHA2DS2-VASc will automatically pop-up if indication is a fib



will turn this into an interpretative calc at some point
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MEDICATION PROFILE Import this section from 'Shared Templates' menu
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ALLERGIES/ADRs:

MEDICATION LIST:


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ASSESSMENT [+] = Yes / True [-] = No / False
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RENAL & LIVER FUNCTION:


SAEFTY:


I will be adding to the DDI section later. I'll include what the expected interaction is (PD vs PK and what the mechanism is) and what the guidance for adjustments is.
DRUG-DRUG INTERACTIONS:


DOSING APPROPRIATENESS:


RISK VS. BENEFIT:
Given the patient's indication for anticoagulation therapy and safety profile (as assessed by history of bleeding events, platelets, hemoglobin, hematocrit, and signs or symptoms of bleeding):


ADHERENCE:

My conditionals are often not working, so if you select that adherence is suboptimal, you should now see the word 'test'.

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PLAN
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anticoagulant

trying to find a way to recall several variables at once - ie doac name, dose/sig, etc; however, something is broken and cannot recall multiple variable at once; will investigate further
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
EDUCATION
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Regarding the patient's anticoagulation therapy, the following points (at aminimum) were addressed:
- Medication name, identification, proper storage, and dosing schedule
- Indication for therapy
- Signs and symptoms of bleeding and thromboembolic events
- Adherence/refill process
- Monitoring requirements
- Interacting medications
- Planned invasive procedures
- Contact information for the Anticoagulation Service

For ongoing monitoring, a population-based approach will be used to ensure
safety, adherence to therapy, and appropriateness of prescribing. Periodic risk/benefit assessments will be performed as necessary.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.56, 52 form elements, 178 boilerplate words, 10 text boxes, 5 text areas, 1 dates, 3 checkboxes, 2 check lists, 13 drop downs, 1 variables, 6 comments, 11 conditionals, 60 total clicks
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