cardiac rehabilitation assessment form

8/19/2019 Cardiac Rehabilitation Assessment Form

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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 1 of 14

pPCI CARDIAC REHABILITATION ASSESSMENT

PATIENT DETAILS GP DETAILS

DOB: Unit No.:

Likes to be called: ......................................... GP Tel No: .............................................................

Tel No’s: ......................................................... Communication issues: .......................................

.......................................................................... ................................................................................

.......................................................................... Religion: ................................................................

M / F Age: ......................... Referral Date: ........................................................

Invited for Rehab: .................................................

NOK Details Rehab Started: ......................................................

Name: .............................................................. Consent Given: YES / NO

Relation: ......................................................... Ethnicity: White / Black / African / Chinese /

Tel No: ............................................................ Black Caribbean / Bangladeshi / Indian / Other:

Referral Source: Consultant / Nurse ............../ GP / Other (please state): ....................................

Assessed By: ME / LS / CS / AS / CH ........................................................................................

EM / TC / HN / MM / KB / TO / RW / HH .............................................................

Datacam: In pt CRass Phase 4 / Discharge

Admiss ionDate Initiating Event Trop InitiatingTreatment Date Consultant DischargeDate

Admission Details: ......................................................................................................................................

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CARDIAC / VASCULAR MEDICAL HISTORY

TYPE DATE DETAILS TYPE DATE DETAILS

MI Angina

Surgery ACS

PTCA CABG

ArrestValve

Surgery

HeartFailure

Pacemaker

Transplant ICD

Congenital LV Assist

PVD TIA

CVA Other

NONE

GENERAL PAST MEDICAL HISTORY

DETAILS DETAILS

Arthritis / Osteoarthritis Rheumatism

Cancer Back Problems

Asthma Osteoporosis

Bronchitis AIDS/HIV

Emphysema Claudication

Diabetes

Other co-morbidComplaints

Details:

CORONARY HEART DISEASE RISK FACTOR PROFILE

Hypertension Hyperlipidaemia

Smoking Diabetes

Family History Overweight

Excess Alcohol Low Levels of Activity


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SOCIAL CIRCUMSTANCES

Marital Status: Single / Married / Permanent Partner / Divorced / Widowed

Accommodation: House / Flat / Bungalow / Sheltered / Warden Controlled / Boat / Caravan

/ Nursing Home / Other ..........................................................................

Patient Lives With: Partner / Spouse / Alone / Relative / Dependants / Other ......................Details/Concerns ..................................................................................................................

Working Status: Full Time / Part Time / Retired / Self-employed / Unemployed / Disabled /Looking for Work / Permanently Sick / Temporarily Sick / Student /Gov. Training Scheme / Looks after Family / Other ................................

Job Title: ..................................................................................................................

Social EconomicGroup: I / II / IIIM / IIIN / IV / V

INITIAL ASSESSMENT

Driving Regulations Explained: Y / N / NA ....................................................

Rules of Chest Pain Discussed: Y / N ....................................................

When to call 999: Y / N ....................................................

Cardiac Rehab Info Booklet Provided: Y / N ....................................................

INVESTIGATIONS/TESTS

Test Date Comments

Echo:..............................................................................................................................................

.......................................................................

ETT:

ECG: Rhythm

Rhythm

APPOINTMENTS

Date Details

Rehabilitation Appointments

CRASS

Exercise Start

Graduation

Medical Appointments

Cardiac Investigations


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NAME DESIGNATION SIGNATURE DATE

MARION ELLIOT Senior Nurse

TRISH OSBALDESTONCardiac

Rehabilitation Nurse

TESSA COBBCardiac


HELEN NOLTECardiac


MIRANDA MOWBRAYCardiac


KATE BLAYNEYCardiac


EMMA MILLSCardiac


RACHAEL WALKERCardiac


CardiacRehabilitation Nurse

HANNAH HINDMARSH Exercise Physiologist

Exercise Physiologist

LYNN SCHOFIELD

Clinical Nurse

Specialist

CAROL SCHOFIELDCardiac


ALEX SMITH Cardiac


CATH HAWLEYCardiac


Exercise Physiologist


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MEDICATION RECORD

Known Allergies:- ................................................................................................

DRUG GROUPDATE DATE DATE DATE

Name & Dose Name & Dose Name & Dose Name & Dose

Beta Blockers Bisoprolol ...... mg

Atenolol ...... mg

Bisoprolol ....... mg

Atenolol ....... mg

Bisoprolol ....... mg

Atenolol ....... mg

Bisoprolol ...... mg

Atenolol ...... mg

ACE InhibitorRamipril ...... mg Ramipril ....... mg Ramipril ....... mg Ramipril ...... mg

A2 Antagonist

Statin / Fibrates Atorvastatin ..... mgSimvastatin ...... mg

Atorvastatin ...... mg

Simvastatin ...... mg

Atorvastatin ...... mg


Atorvastatin ..... mg


Aspirin75 mg 75 mg 75 mg 75 mg

Other Anti-Platelets Prasugrel

Clopidogrel 75 mg

Prasugrel

Clopidogrel 75 mg

Prasugrel

Clopidogrel 75 mg

Prasugrel

Clopidogrel 75 mg

Digoxin..................mcg .................. mcg .................. mcg .................. mcg

Diuretics

Nitrate

GTN Spray/Tabs

Pre-admissionMedies

Others:- Others:- Others:- Others:-


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IN PATIENT ASSESSMENTDate:

pPCI FOLLOW UP CLINICDate:

Chest Pain / Wound Pain / Heart FailureCCS 0 / I / II / III / IV

Details: .....................................................................

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Explanation of Medications: Y / N

Heart Failure Assessed Y / N

Echo Performed Y / N

Comments: ...............................................................

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Chest Pain / Wound Pain / Heart FailureSince previous F/U: Y / N CCS 0 / I / II / III / IV

Details: .....................................................................

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Has GTN: Y / N

Aware of Rules of Chest Pain: Y / N

Reported Side Effects of Medication: Y / N

Details: .....................................................................

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ACTIVITY NYHA Class I / II / III / IV

1: Per week how many times does pt. do Activity:

Strenuous ............... Moderate ............ Mild ...........

2: Does Pt sweat during activity:

Often Sometimes Never / Rarely

3: Does pt. do 30 mins Activity5 times per week: Y / N

Type of Activity: ........................................................

..................................................................................

Safe Levels of ActivityPost Discharge Discussed: Y / N

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Current Activity Levels

Safe: Y / N

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Gym Start Date: .......................................................

Driving Resumed: Y / N

Interested in Exercise Sessions: Y / N

SMOKING ASSESSED Y / N

Never Current Ex-Smoker

Type: Cigarettes / Pipe / Rollups / Cigars

Duration: ...................................................................

Smoke Within 30 mins. of Waking: .................. Y / N

Smoking Cessation support offered: ................ Y / N

Referred to PN ...................................................

Advice Given: ...........................................................

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..................................................................................

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Quit Period: ..............................................................

Daily Consumption: .............. Weekly: ..................


Never

Current

Is Ex-Smoker of > 1 Month:

Discussed Quit Attempt: .................................. Y / N

Smoking Cessation support offered: ............... Y / N

Referred to PN ...................................................

Advice Given: ..........................................................

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CARDIAC REHABILITATION ASSESSMENT

Date: END ASSESSMENT

Date:


Details: .......................................................................................................................................................

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Has GTN: Y / N



Heart Failure Assessed: Y / N

Echo Performed: Y / N

Comments: ...............................................................

..................................................................................


Details: ......................................................................................................................................................

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.................................................................................

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Has GTN: Y / N



Heart Failure Assessed: Y / N

Echo Performed: Y / N

Comments: ..............................................................

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Type of Activity: ........................................................

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..................................................................................Role of Exercise inPrevention of CHD Discussed: Y / N







Type of Activity: .......................................................

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Never

Current


Discussed Quit Attempt: ...................................Y / N

Smoking Cessation support offered: ................ Y / N

Referred to PN Quit form sent

Advice Given: ...........................................................

..................................................................................

..................................................................................

..................................................................................

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Never

Current


Discussed Quit Attempt: .................................. Y / N

Smoking Cessation support offered: ............... Y / N

Referred to PN Quit form sent

Advice Given: ..........................................................

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PSYCHOLOGICAL STATE ASSESSED Y / N

HAD Score: ............................................................

Dartmouth Co-op: Y / N

History of Anxiety and Depression Y / N

Psychological support offered Y / NConcerns voiced: ......................................................

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Sexual concerns assessed Y / N

Sexual Counselling offered Y / N

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Return to Work Discussed Y / N

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HAD Score: ............................................................

Psychological support offered Y / N

Referred for Psychological Counselling Y / N

Comments: ..............................................................

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Return to Work Discussed Y / N

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Interested in information sessions Y / N

DIET/WEIGHT MANAGEMENT

Cholesterol Assessed Y / N

Hx of Chol: Y / N Previous Statin Y / N

Date: ................................ Waist > Hip: Y / N

T Chol: ............................. Benefits of Oily Fish

HDL: ................................ Mentioned: Y / N

LDL: .................................

HDL R: .............................

Trig: .................................

BMI Assessed: Y / N

Height: ..............Weight: ............... BMI: ................

Comments: ...............................................................

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ALCOHOL ASSESSED Y / N

Units / Week: ...................

Advice Given: ...........................................................

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Units / Week: ..................

Advice Given: ..........................................................

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CARDIAC REHABILITATION ASSESSMENTDate:

END ASSESSMENTDate:


HAD Score: ............................................................



Comments: ...............................................................

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..................................................................................

Return to Work Discussed: Y / N..................................................................................

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HAD Score: ............................................................



Comments: ..............................................................

.................................................................................

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.................................................................................

Return to Work: Y / N

Date .........................................................................

Full time / Part time / Planned / Unplanned /Unemployed / Looking for work / Temporarily sick / Awaiting further investigation / HGV awaiting ETT .

.................................................................................

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Date: ................................ Waist > Hip: Y / N

T Chol: ............................. Benefits of Oily Fish

HDL: ................................ Mentioned: Y / N

LDL: .................................

HDL R: .............................

Trig: .................................

BMI Assessed: Y / N


Comments: ...............................................................

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Date: ............................... Waist > Hip: Y / N

T Chol: ............................ Benefits of Oily Fish

HDL: ............................... Mentioned: Y / N

LDL: ................................

HDL R: ............................

Trig: ................................

BMI Assessed: Y / N


Comments: ..............................................................

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Units / Week: ...................

Advice Given: ...........................................................

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Units / Week: ..................

Advice Given: ..........................................................

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HYPERTENSION BP Assessed: Y / N

BP: ....................HR: ...................... Rhythm: .........

Treated: Y / N

Good Control: Y / N

Salt Intake Discussed: Y / N

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BP: ....................HR: ............ Rhythm: ...................

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DIABETES Blood Sugars Assessed: Y / N

Type I Diet

Type II Tabs

Insulin

Inpatient Blood Sugar Range: ..................................

Hb A1C ......................................................................

Previous Control: ......................................................

Newly Diagnosed: Y / N

Advice Given: ...........................................................

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Range: .....................................................................

Advice Given: ..........................................................

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Hb A1C .....................................................................

Referred to PN / OCDEM: Y / N

FAMILY HISTORY Assessed: Y / N Mother: .....................................................................

Father: ......................................................................

Siblings: ....................................................................

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FAMILY HISTORY Assessed: Y / N

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CARDIAC REHABILITATION ASSESSMENTDate:

END ASSESSMENTDate:


BP: ....................HR: ............ Rhythm: ...................

Good Control: Y / N


Comments: ...............................................................

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Pre-Exercise

BP: ....................HR: ............ Reg. / Irreg. ..............

Post-Exercise

BP: ....................HR: ............ Reg. / Irreg. ..............

Good Control: Y / N


Comments: ..............................................................

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Result Date: ..............................................................

Blood Sugar Assessed: .....................Random / Lab

HBA1C: ....................................................................

Effective Control: Y / N

Advice Given: ...........................................................

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Attends Practice for Monitoring: Y / N


Result Date: .............................................................

Blood Sugar: Assessed .....................Random / Lab

HBA1C: ....................................................................

Effective Control: Y / N

BM pre- Exercise: ....................................................

BM post-Exercise: ...................................................

Advice Given: ..........................................................

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Attends Practice for Monitoring: Y / N


Discuss with the Patient the Healthof their Children : Y / N

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Discuss with the Patient the Healthof their Children : Y / N

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ATTENDANCE / APPOINTMENT INFORMATION

NAME: ..................................................................................................................................................

Patient has dates for the Information Sessions: Y / N

Horton Information Sessions

Week Topic Date

1 Healthy Eating

2 Understanding Heart Disease

3 Emergency First Aid

4 Pharmacist and Blood Pressure

5 Risk Factor Summary

6 Physical Activity and Heart Disease

7 An Introduction to Relaxation

8 Managing Day to Day Stresses

JR Information Sessions

Week Topic Date

1Understanding Heart DiseasePhysical Activity

Stress and Relaxation

2MedicationsHealthy Eating and Food LabellingCBT


13/14


CARDIAC REHABILITATION EXERCISE ASSESSMENT

NAME ............................................. AGE ...... EXERCISE START DATE

Grad Date

.....................................

.....................................

PROGRESS (since discharge – note any symptoms)

If surgical 12 weeks since op:

CURRENT PA (FITT) and advice given GTN Y NOn Person? Y N Guidelines? Y N

PREVIOUS PA

EXERCISE LIMITATIONS ADAPTIONS TO EXERCISE

POSSIBLE MEDS SIDE EFFECTS / PA CONSIDERATIONS PATIENT CONCERNS

PATIENT GOALS ADDITIONAL COMMENTS

Actual / Predic ted

MRH ..................... RHR ................. HRR ................... BB? Y N

TRH40% ...................... 50% ................. 60% .............. 70% ................... 80% ...................

RISK STRATIFICATION LOW MODERATE HIGH Permission required Y N

Comments: Permission received Y N

CHECKLIST Discussed w ith Patient

Up to 10 Weeks? Y N

Sensible Precautions? Y N

Warm up / Cool down? Y N

Effort score? Y N

Safety advice? Y N

Exercise book given? Y NHome exercise? Y N

EP INITIALS ........................ SIGNATURE ............................................................. DATE ............................


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SUPERVISED EXERCISE PROGRAMME Site: Horton / Abingdon / BBL / Witney

Start Date: ................................................. Finish / Discharge Date: .........................................................

Graduated: Y / N If No reason for Discharge: ....................................................

No. of Sessions Attended ........................ % of Gym Attendance .............................................................

Plan For Future Exercise

Exercise Level Achieved: .........................mins Phase IV

Exercise HR Achieved: .............................bpm Exercise Referral Scheme

Target HR: ................................................bpm Independent Gym

Working at RPE: ..................(Borg 0-10 scale) Independent Exercise

Limitations During Exercise: ............................ No Regular Exercise

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Referral Form Required: Y / N Referral Form Completed: ........................................

Sent To: ..............................................................................................................................................

cardiac rehabilitation assessment form

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