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