Download CONGESTIVE HEART FAILURE CORE MEASURE DATA

CONGESTIVE HEART FAILURE
CORE MEASURE DATA COLLECTION WORKSHEET
MRUN:_____________
Race: € White € Black/African American € American Indian
Account #_____________________ € Asian € Native Hawaiian or Pacific Islander € Undetermined
Birth Date:____________________
Hispanic ethnicity or Latina: € Yes € No/Undetermined
Physician:_________________________ Room #___________________________
Admit Date:_______________________ Discharge Date:_____________________
Facility: __________________________Collected by:________________________
Standing orders used?
€Yes €No
Left Ventricular Function Assessment Documentation
Left Ventricular Ejection Fraction:_____________
Narrative Left Ventricular Function Description:
€ Normal to Mild LVSD € Moderate to Severe LVSD
€Yes €No
€Yes €No
€Yes €No
€
LVEF Unknown/UTD
During Stay
Prior to Stay
Planned after discharge
Use of ACEI/ARB Information
€ Yes € No Is both a potential contraindication/reason for not prescribing ACEI at discharge and a
potential contraindication/reason for not prescribing ARB at discharge documented?
€ Yes € No Was an ACEI prescribed at discharge?
€ Yes € No Was an ARB described at discharge?
Adult Smoking Counseling Documentation
€Yes €No
€Yes €No
Did the patient smoke cigarettes anytime during the year prior to hospital arrival?
Was the patient given smoking cessation advice or counseling during this hospital stay?
Discharge Instructions
€Yes
€Yes
€Yes
€Yes
€No
€No
€No
€No
Discharge instructions given?
Medications
Weight Monitoring
Diet and Activity
Met all Measures:
€Yes €No
€Yes €No
€Yes €No
Follow-up
Symptoms Worsening