Heart Failure Transition Care Form - Vancouver Island Health Authority

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EMBOSS WITH PATIENTS HOSPITAL ID CARD
Name:
PHN:
DOB:
MRN:
Heart Failure Transition Care
Discharge from hospital form. Copy to be faxed to primary care physician/nurse practitioner; copy to patient & chart.
Discharge
Admission Date
Discharge Date
MRN:
Diagnosis:
day/month/year
day/month/year
PATIENT EDUCATION (form completed by RN)
 Daily weight, before breakfast
 Received copy of
Living Well with Heart Failure
 Limit salt/sodium to less than 2000 mg per day
 Reviewed use of Heart Failure Zones with patient
 Limit fluid to less than 1500 mL per day or ________ per day, if
 Reviewed signs & symptoms of worsening heart
taking a water pill regularly
failure
 Take medications as prescribed
 Review heart failure medication use and dose
 Daily activity, as tolerated
 Avoid non-steroidal anti-inflammatory drugs (NSAIDS)
 Review Heart Failure Zone sheet daily to monitor symptoms
 Smoking cessation
 not applicable
PATIENT SPECIFIC DISCHARGE INFORMATION (form completed by RN or MD)
 BP: Lying ____________ Standing ______________
NYHA class on discharge:  I
 II
 III
 IV
 Pulse: __________
Ideal dry weight: ___________  kg  lbs
 Discharge weight: ___________  kg  lbs
Target INR
 2.0 – 3.0
 2.5 – 3.5
 not applicable
MOST RECENT TEST RESULTS
(form completed by RN or MD)
 Ejection fraction: ________ %
Date _____________
Na __________
Date of lab results______________
by  Echo  MUGA  angiogram  _________
+
day/month/year
K
__________
day/month/year
Cr ___________
 ECG rhythm _________________________ Date _____________
eGFR _________
INR _________
day/month/year
FOLLOW-UP APPOINTMENTS/REFERRALS ON DISCHARGE (form completed by clerk)
Date faxed & initials
 Primary care practitioner in ______________ weeks
 Home and Community Care
 Heart Function Clinic (with referral Form)
 Specialist _______________________ in ___ weeks
 Telehome Care for Home
 Heart Function Clinic in __________________ weeks
Heart Failure Monitoring
 _____________________________________ weeks
 BC Palliative Care Benefits Form
 _____________________________________ weeks
faxed to: 250-405-3587
 Palliative Care
 Other _______________________
PENDING TESTS TO BE COMPLETE AS OUTPATIENT (form completed by clerk)
Blood work  Given requisition, primary care practitioner copied
_________ days
 _________________________________ in
Na, K, Cl, Cr, eGFR in _________ days
_________ days
 _________________________________ in
 INR on/in ___________________ day(s)
Booked by VIHA:
(test, date, time)
 Holter
 Nuclear medicine
 Echo
 Pacemaker Clinic
TESTS TO BE ARRANGED BY GP/NP:
FORM FAXED WITH COPY OF DISCHARGE MEDICATION LIST TO (form completed by clerk) :
Fax Number
Date: ________________
Primary care practitioner _______________________
_________________
day/month/year
Cardiologist /Internist__________________________
_________________
MRP ________________________________________
Signature of
_________________
person faxing form:
Other _____________________________________
_________________
 Copy of Discharge Medication List faxed to physicians with Transition Tool
 Copy of Heart Failure Transition Tool given to patient or family member

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