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Admission Dx: Cardiac Procedure
Date Case Referred:
Case Manager:
Last Name:
DOB/Age:
Admit Date:
Review Type:
Attending:
Admitting Dx:
Case Manager Contact #:
First Name:
Gender:
D/C Date:
Payer/Member ID:
Attending Contact #:
Physician Order (inpatient, obs, outpatient):
Is this a READMISSION REVIEW (within 30 days)?
If Yes, please answer the following:
Dates of previous admission:
Inpatient or Observation on previous admission:
Discharge diagnosis:
Was patient stable or at baseline at discharge:
Brief description of patient at discharge:
Type of Procedure Performed:
Device Procedure:
____ Pacemaker
____ Defibrillator
____ Lead Replacement, Generator Replacement
or Revision
Diagnostic Procedure:
____ Coronary Catheterization
____ Coronary Angiography
____ Endomyocardial Biopsy
____ Electrophysiologic Studies
Type of Secondary Procedure Performed:
Device Procedure:
____ Pacemaker
____ Defibrillator
____ Lead Replacement, Generator Replacement
or Revision
Diagnostic Procedure:
____ Coronary Catheterization
____ Coronary Angiography
____ Endomyocardial Biopsy
____ Electrophysiologic Studies
Therapeutic Interventional Procedures:
____ Coronary Stent
____ PTCA
____ Cardiac Ablation
____ Coronary Atherectomy
____ Coronary Brachytherapy
____ Laser Angioplasty
Therapeutic Interventional Procedures:
____ Coronary Stent
____ PTCA
____ Cardiac Ablation
____ Coronary Atherectomy
____ Coronary Brachytherapy
____ Laser Angioplasty
Indication for Procedure:
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Updated: Oct 2012
Admission Dx: Cardiac Procedure
The Procedure Was:
____ Scheduled / Elective
____ Urgent / Emergent
HPI:
Outpatient Workup/Treatment:
Past Medical History:
Cardiac History (List dates of procedures, if available):
NYHA Class: I II III IV
Ejection Fraction: %
Killip Score:
Previous Cardiac Procedures:
Previous MI:
Medications:
Physical Exam:
Labs (Pre- or post procedure, list when they were performed, include reference range):
Procedure Outcome:
CATH (results):
ICD/PACER:
____ Single chamber
____ Dual chamber
____ Biventricular
Was the device tested after the procedure?
Stent:
# Stents:
Vessels:
Procedure Start Time: __:__
Procedure Finish Time: __:__
Duration of Surgery:
Type of Anesthesia:
____ General
____ Sedation/MAC
____ Peripheral nerve block
____ Spinal/Epidural/Caudal
Intra- and Post-Operative Complications (If any):
Post Procedure Orders:
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Updated: Oct 2012
Admission Dx: Cardiac Procedure
Additional Information:
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Updated: Oct 2012