Microsoft word - lcd cardiac.doc

                               Heart Disease
The purpose of this worksheet is to guide initial and recertification assessments. This is a guide only; clinical judgment is required in each case. This worksheet is completed and signed by the RN and attached to a completed
Admission/Recertification Evaluation form. After reviewing the completed paperwork, the Medical Director will sign the
Admission/Recert Evaluation form and Recertification form for hospice eligible clients.
Client Name: ___________________________ Medical Record Number: _________ Date: _________
The patient must have 1or 2 and 3.
1. Poor response to (or patient’s choice is not to pursue) optimal treatment with diuretics, vasodilators, and/or angiotensin converting enzyme (ACE) inhibitor 2. The patient has angina pectoris at rest resistant to standard nitrate therapy and is not a candidate for invasive procedures and/or has declined revascularization procedures 3. New York Heart Association (NYHA)* Class IV symptoms with both of the following: *See appendix 1 for New York Heart Association (NYHA) Functional Classification The presence of significant symptoms of recurrent Congestive Heart Failure (CHF) and /or angina at rest Inability to carry out even minimal physical activity with symptoms of heart failure (dyspnea and/or angina)
Supporting evidence for hospice eligibility:
_____Echo demonstrating an ejection fraction of 20% or less
_____Treatment resistant symptomatic dysrythmias
_____History of unexplained or cardiac related syncope
_____CVA secondary to cardiac embolism
_____History of cardiac arrest or resuscitation
_____ Concomitant HIV disease.
_____Wt loss history last 6 months:__________________________________________
_____Systolic b/p less than 90 or progressive postural hypotension
_____BMI below 22 kg/22m2 within last 6 months:(dates)_______________________
_____Decreasing arm circumference_________________________________________
Examples of Diuretics, Vasodilators, (ACE) inhibitors: Diuretics Check all that apply. _____ Furosemide (Lasix) _____ Ethacrynic Acid (Edecrin) _____ Bumetanide (Bumex) _____ Torsemide (Demex) _____ Metolazone (Zarloxlyn, Mykrox – may be combined with above, but not used alone.) Vasodilators Check all that apply. A. Nitrates (e.g., Nitro patch, Isosorbide) plus Hydralazine _____ B. Aprespline Anglotensin Converting Enzyme (ACE) Inhibitor: _____ Benazepril (Lotensin) _____ Lisinopril (Prinvil. Zestril) _____ Captopril (Capoten) _____ Quinapril (Accupril) _____ Enalapril (Vasotec) _____ Ramipril (Altace) 7/15/10                                                                      macintosh  downloads:lcd  cardiac.doc  
Signs and Symptoms of NYHA Class IV disease:
_____ Dyspnea at rest: “short winded,” “can’t breathe.” _____ Dyspnea on exertion: “Can’ breathe with _____ Orthopnea: “Can’t breathe lying down.” _____ Neck veins distended above clavicle. _____ Paroxysmal nocturnal Dyspnea (PND): “Waking _____ Rales: Wet crackles in lungs heard on inspiration. _____ Edema: “Swollen ankles, legs.” _____ Chest Pain.  Co-morbitities/Secondary Conditions that support hospice diagnosis: Person completing form signature_________________________________________________________Date:____________ RN signature_________________________________________________________Date:_____________ Md. Signature___________________________________________________________Date:_______________ 7/15/10                                                                      macintosh  downloads:lcd  cardiac.doc  


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