pPCI CARDIAC REHABILITATION ASSESSMENT

PATIENT DETAILS

DOB:

GP DETAILS

Unit No.:

Likes to be called: .........................................

GP Tel No: .............................................................

Tel No’s: .........................................................

Communication issues: .......................................

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

M/F

Referral Date: ........................................................

Age: .........................

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:
Admission
Date

In pt
Initiating Event

CRass
Trop

Initiating
Treatment

Phase 4 / Discharge
Date

Consultant

Discharge
Date

Admission Details: ......................................................................................................................................
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CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

1 of 14

5Pathway Oct2011 Hypertension Hyperlipidaemia Smoking Diabetes Family History Overweight Excess Alcohol Low Levels of Activity Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 2 of 14 .CARDIAC / VASCULAR MEDICAL HISTORY TYPE DATE DETAILS TYPE DATE MI Angina Surgery ACS PTCA CABG Arrest Valve Surgery Heart Failure Pacemaker Transplant ICD Congenital LV Assist PVD TIA CVA Other DETAILS NONE GENERAL PAST MEDICAL HISTORY DETAILS DETAILS Arthritis / Osteoarthritis Rheumatism Cancer Back Problems Asthma Osteoporosis Bronchitis AIDS/HIV Emphysema Claudication Diabetes Other co-morbid Complaints Details: CORONARY HEART DISEASE RISK FACTOR PROFILE CRF v4.

................................ Details/Concerns ............................................................................................................................................................................................... Echo: ................. ......... Job Title: ...................................................... Cardiac Rehab Info Booklet Provided: Y/N ... Working Status: Full Time / Part Time / Retired / Self-employed / Unemployed / Disabled / Looking for Work / Permanently Sick / Temporarily Sick / Student / Gov.............................................................5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 3 of 14 ....................................................................SOCIAL CIRCUMSTANCES Marital Status: Single / Married / Permanent Partner / Divorced / Widowed Accommodation: House / Flat / Bungalow / Sheltered / Warden Controlled / Boat / Caravan / Nursing Home / Other ................................................. Training Scheme / Looks after Family / Other ........................ Patient Lives With: Partner / Spouse / Alone / Relative / Dependants / Other ................... INVESTIGATIONS/TESTS Test Date Comments .................................................................... When to call 999: Y/N ............................................................................................ Social Economic Group: I / II / IIIM / IIIN / IV / V INITIAL ASSESSMENT Driving Regulations Explained: Y / N / NA ................................ Rules of Chest Pain Discussed: Y/N ................................. ETT: Rhythm ECG: Rhythm APPOINTMENTS Date Details CRASS Rehabilitation Appointments Exercise Start Graduation Medical Appointments Cardiac Investigations CRF v4............................

5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 4 of 14 .NAME DESIGNATION MARION ELLIOT Senior Nurse TRISH OSBALDESTON Cardiac Rehabilitation Nurse TESSA COBB Cardiac Rehabilitation Nurse HELEN NOLTE Cardiac Rehabilitation Nurse MIRANDA MOWBRAY Cardiac Rehabilitation Nurse KATE BLAYNEY Cardiac Rehabilitation Nurse EMMA MILLS Cardiac Rehabilitation Nurse RACHAEL WALKER Cardiac Rehabilitation Nurse SIGNATURE DATE Cardiac Rehabilitation Nurse HANNAH HINDMARSH Exercise Physiologist Exercise Physiologist LYNN SCHOFIELD Clinical Nurse Specialist CAROL SCHOFIELD Cardiac Rehabilitation Nurse ALEX SMITH Cardiac Rehabilitation Nurse CATH HAWLEY Cardiac Rehabilitation Nurse Exercise Physiologist CRF v4.

.MEDICATION RECORD Known Allergies:............. mg Atorvastatin ..... mg Ramipril .. mg Bisoprolol . DATE DATE DATE DATE Name & Dose Name & Dose Name & Dose Name & Dose DRUG GROUP Beta Blockers Bisoprolol ........ mg Ramipril ........ mg Atenolol ........ mg ACE Inhibitor A2 Antagonist Statin / Fibrates Atorvastatin ............. mg Atenolol ............. mg Atenolol ........ mg Simvastatin .......................... mg Atenolol ........... mg Ramipril .......mcg .......................... mg Simvastatin ......... mg 75 mg 75 mg 75 mg 75 mg Aspirin Other Anti-Platelets Digoxin Prasugrel Prasugrel Prasugrel Prasugrel Clopidogrel 75 mg Clopidogrel 75 mg Clopidogrel 75 mg Clopidogrel 75 mg ............ mg Atorvastatin ..... mcg ...... mg Simvastatin ................ mg Bisoprolol ........... mg Atorvastatin ............. mg Ramipril ... mg Simvastatin .......... mg Bisoprolol ...................5Pathway Oct2011 Others:- Oxford University Hospitals NHS Trust Others:- To be Reviewed Oct 2012 Others:- Others:- 5 of 14 .................. mcg ............ mcg Diuretics Nitrate GTN Spray/Tabs Pre-admission Medies CRF v4...........

......................................................................................... .... ........................... ........................................................................ .......................................................... Mild ........................................................................................................... ......... ............... ....... .....................................................................Y / N Smoking Cessation support offered: .... .................................................. of Waking: ....................... ACTIVITY NYHA Class I / II / III / IV ACTIVITY NYHA Class I / II / III / IV Current Activity Levels 1: Per week how many times does pt........................................... 2: Does Pt sweat during activity: Often Sometimes 3: Does pt. do 30 mins Activity 5 times per week: ........................................................................................ Y/N .......................... Daily Consumption: ..................................................... ................... Y / N Referred to PN ........................... Driving Resumed: Y/N Interested in Exercise Sessions: Y/N SMOKING ASSESSED Never Type: SMOKING ASSESSED Y/N Current Ex-Smoker Cigarettes / Pipe / Rollups / Cigars Never Current Is Ex-Smoker of > 1 Month: Duration: ................ .................................................................................................................................................................. ............... Moderate .......................................... Y / N Smoking Cessation support offered: .................................................. Advice Given: ...................................................................................................... .... . Has GTN: Y/N Aware of Rules of Chest Pain: Y/N Reported Side Effects of Medication: Y / N Explanation of Medications: Heart Failure Assessed Echo Performed Y/N Y/N Y/N Details:.............. Gym Start Date: ................................................................................................................................................................................................................................... ..................... Smoke Within 30 mins.......................................................... ........................................................................... ...... Safe Levels of Activity Post Discharge Discussed: Y/N ......................... .....................................................................................................................................................................Y / N Referred to PN ........... Quit Period: ................................................................... ............................................................................................................................... ........................... ........... CRF v4...................................................... .................................................... Y/N Type of Activity: .................. ..................................... Y/N Discussed Quit Attempt: .....................................................IN PATIENT ASSESSMENT pPCI FOLLOW UP CLINIC Date: Date: Chest Pain / Wound Pain / Heart Failure CCS 0 / I / II / III / IV Chest Pain / Wound Pain / Heart Failure Since previous F/U: Y / N CCS 0 / I / II / III / IV Details: ................................................................... .............................................................................................................. ........................................................................................................................................................................................................................................................... ............ Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 6 of 14 .........................................................................................5Pathway Oct2011 Weekly: ................................................................................................................................................................................................................................................................................................................................... do Activity: Safe: Strenuous ..................................................... Never / Rarely ..................... Details:............................... Advice Given: ....................................................................................... ................................................................. Comments: ......................................................................

............... ............................. ................... ..................... . ...................................................................................................................................................... ............................5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 7 of 14 ....................................................................... ....................................................... ........................................................... ................................................................... do Activity: 2: Does Pt sweat during activity: Sometimes 3: Does pt............................................................................................................................................................................................................................ .... Has GTN: Aware of Rules of Chest Pain: Reported Side Effects of Medication: Heart Failure Assessed: Echo Performed: Has GTN: Aware of Rules of Chest Pain: Reported Side Effects of Medication: Heart Failure Assessed: Echo Performed: Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Comments: ..................... Never Current Is Ex-Smoker of > 1 Month: Y/N Never Current Is Ex-Smoker of > 1 Month: Discussed Quit Attempt: .. do Activity: Strenuous ........................................................................... ...... ............ ...................................... ................................................... CRF v4.............. Mild ................................................................................ do 30 mins Activity 5 times per week: NYHA Class I / II / III / IV 1: Per week how many times does pt............................................................. .................. ........................................................ ............................................................................ Moderate ....................... Y / N Smoking Cessation support offered: ....................... .............................................................. Often ACTIVITY Strenuous .............................. Comments: ...................................................... .........................CARDIAC REHABILITATION ASSESSMENT Date: END ASSESSMENT Date: Chest Pain / Wound Pain / Heart Failure Since previous F/U: Y / N CCS 0 / I / II / III / IV Chest Pain / Wound Pain / Heart Failure Since previous F/U: Y / N CCS 0 / I / II / III / IV Details: ............................................................................................ .................................................................................................................................... SMOKING ASSESSED SMOKING ASSESSED Y/N .................................................. Moderate ....................................................................... ACTIVITY NYHA Class I / II / III / IV 1: Per week how many times does pt....................... do 30 mins Activity 5 times per week: Y/N Never / Rarely Y/N Type of Activity: ...................................Y / N Discussed Quit Attempt: ..........................................................Y / N Smoking Cessation support offered: ......................................................................................................................................................................................................................................... .......................................................................................................................................................... ................. ................................................................... Advice Given: .......................................................................... ................................................................................................................. 2: Does Pt sweat during activity: Often Never / Rarely Sometimes 3: Does pt....... ............. Type of Activity: .... Mild ......................................................................................................................................................... Details:................ Role of Exercise in Prevention of CHD Discussed: Y/N ............................................... ........................................................................... Y / N Referred to PN Referred to PN Quit form sent Quit form sent Advice Given: .................................................................................................................................. ......

........................................ HDL R: ................................................................................................................................... ................................................................................................... Psychological support offered Y/N Referred for Psychological Counselling Y / N Comments: ............................................................................................................................ ........................................................... ......................................................................................................................... ALCOHOL ASSESSED Y/N ...............................IN PATIENT ASSESSMENT pPCI FOLLOW UP CLINIC Date: Date: PSYCHOLOGICAL STATE ASSESSED Y/N HAD Score: ............... Return to Work Discussed Y/N ............. Waist > Hip: Y/N T Chol: ......... Mentioned: ............................................................................... ......... BMI: ........................... .... ................................................ .................................................................................. .. .......... .......... Comments: .................................................................................................................................................. BMI Assessed: .................................................................................................................................................................................................................................................................................................. Y/N Height: ........................... ................. ................................................................................................................................................................... Return to Work Discussed Y/N .................................................................................................................................................................................................................................................................... ................................................................ ........................ ...................................................................................... .................................................................................................. ...................................... Advice Given: .......................................................................................................................... ................................................................................. Cholesterol Assessed Hx of  Chol: Y/N Y/N Y/N ........... Y/N ....................................................... Weight: ............................................................... ................................................... ................................................................... ................................................................................... CRF v4........................................................................................................... Dartmouth Co-op: Y/N History of Anxiety and Depression Y/N Psychological support offered Y/N Concerns voiced:......................................................... Trig: ...................................................................... Advice Given: ....................... .............................................. ................... .......................................................... ................................................................................5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 8 of 14 ................................................... Sexual concerns assessed Sexual Counselling offered ......... Benefits of Oily Fish HDL: ............................... ................................................................................ Units / Week: ...................................................... ............................................................................ LDL: .............. ........................................................................................................... Interested in information sessions DIET/WEIGHT MANAGEMENT Y/N Y/N DIET/WEIGHT MANAGEMENT Y/N Previous Statin Y/N Date: .......................................... ....... ............................................. ............................................................................. ALCOHOL ASSESSED Y/N Units / Week: ........................................................................................ Sexual concerns assessed Sexual Counselling offered Y/N Y/N PSYCHOLOGICAL STATE ASSESSED HAD Score: .............................................................................................. .......................................... ....................................................................................................................................... ............................................................................ ........................................

................................................ ............................ CRF v4............................ Return to Work: Y/N Date ................................................. BMI: .......... .................................................. Comments: .............................................................. Trig: . Weight: .......... Trig: ........................ .......... Waist > Hip: Y / N Date: ......................................................................................................................... Psychological support offered Y/N Referred for Psychological Counselling Y / N Psychological support offered Y/N Referred for Psychological Counselling Y / N Comments: ................ Comments: ........... .......................................... ............ Advice Given: ..................................... ...... Benefits of Oily Fish HDL: .............. Mentioned: Y / N LDL: .................................................................................................................................................. Waist > Hip: Y / N T Chol: ............................. Return to Work Discussed: Y/N ................................. DIET/WEIGHT MANAGEMENT Cholesterol Assessed DIET/WEIGHT MANAGEMENT Cholesterol Assessed .... Full time / Part time / Planned / Unplanned / Unemployed / Looking for work / Temporarily sick / Awaiting further investigation / HGV awaiting ETT ......................................................................................................................... BMI: ................................ ...................................................... ......... ............................................................ ...................... .................................... Benefits of Oily Fish T Chol: ...................................................................................................................................................................................................................................................................................................................................................... ...................................................................... BMI Assessed: Y/N BMI Assessed: Y/N Height: .....5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 9 of 14 ............................................................................ LDL: ............................................... Units / Week: ........................................................................................................................................ . ........................................... .................................... .............................. ......................................... Weight: ................................................................................................................................................................................................................................. .................................. ..................................... ....... ................................................................. Height: ........................................................................................................................................... ................................. Comments: ................................. Mentioned: Y / N HDL: .......... Sexual concerns assessed Sexual Counselling offered Sexual concerns assessed Sexual Counselling offered Y/N Y/N Y/N Y/N .......................................................................................................................................................................................................................................................................... HDL R: ........................................................................................................ ................................. HAD Score: ..................................... .............................. ALCOHOL ASSESSED Y/N ALCOHOL ASSESSED Y/N Units / Week: .................................................................................................... HDL R: ............ Advice Given: ..................................................................................................................................... Y/N Y/N Date: ..... .....................................................CARDIAC REHABILITATION ASSESSMENT Date: PSYCHOLOGICAL STATE ASSESSED Y/N END ASSESSMENT Date: PSYCHOLOGICAL STATE ASSESSED Y/N HAD Score: .................. ..................................................................... .................................................................... ..............................................................................................................................

.............................................................................. DIABETES Type I Type II Blood Sugars Assessed: Y/N ......................................................................................................................................................... Newly Diagnosed: Y/N ................... ........................................................................................................................... ........................................................................ HR: .......... Father: ......................................................................................... .............................. Rhythm: ............. .............................................................................................................. HR: .................................................. ......................................................................................................................................................................................................... DIABETES Blood Sugars Assessed: Y/N Range: .................................................................... .............................. Advice Given: ...................... FAMILY HISTORY ............ ................ ................................................................ Y/N ................... Diet Tabs Insulin Advice Given: ........... ........................................................................ Referred to PN / OCDEM: FAMILY HISTORY Y/N Assessed: Y/N Mother: ..................................................... HbA1C .................. Siblings: ............................ ............ .......................................................................................................................................................................... ........................................ CRF v4..... Treated: Good Control: Salt Intake Discussed: ............................................................... ....................................................................................... ........................................................... ..................................................................... HbA1C ............................................................... Previous Control: ................. Assessed: ............................................................ Y/N Y/N Y/N ............. .............................................................................. BP: ....... Rhythm: ............... ... ....................................................................................................................................................................... ................................................................................................................................................................................................................................................. ........................................................................................................................................................ ....................... .................................................. ....... ... .......................................................................................................................................................................................................................... ............................................................................................................................................................................................................... ......................................................................................................................................................IN PATIENT ASSESSMENT pPCI FOLLOW UP CLINIC Date: Date: HYPERTENSION BP Assessed: Y/N HYPERTENSION BP Assessed: Y/N BP: .............................................................5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 10 of 14 ............................... .. Inpatient Blood Sugar Range: ................................................................................ ...........................................................................................................................................

................. HR: ............ ........................................................................................................ Result Date: ....... BP: .. ........................................... ................................................... HR: ..................................................................................................................................................... .................................................. HR: ................................ Blood Sugar Assessed: ........................................................................................................................... Advice Given: ...... ......................................................................................................... BM post-Exercise: ......................................... / Irreg...................................................................................................................................... Comments: ....... Reg......................................................................................................................................... ........................................................................................... .................. Rhythm: . ........5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 11 of 14 .................................................................................................................................. Random / Lab Blood Sugar: Assessed ....................................... DIABETES Blood Sugars Assessed: Y/N DIABETES Blood Sugars Assessed: Y/N Result Date:................. CRF v4....................... ......................... .. ......... ............. BM pre............................................................................................................................................................................. .......................................................................................................................................................................................................Exercise: ...........................................................................................................................CARDIAC REHABILITATION ASSESSMENT Date: HYPERTENSION BP Assessed: Y/N BP: .......................... Referred to PN / OCDEM: Referred to PN / OCDEM: Y/N Attends Practice for Monitoring: Y / N FAMILY HISTORY Attends Practice for Monitoring: Y / N Assessed: Discuss with the Patient the Health of their Children : Y/N Y/N FAMILY HISTORY Assessed: Discuss with the Patient the Health of their Children : Y/N Y/N Y/N ........ .......... ... ...................... Random / Lab HBA1C: ........................... Reg......................... ............................................................................................ .................................. Good Control: Y/N Salt Intake Discussed: Y/N Post-Exercise Comments: .............................................................................................. END ASSESSMENT Date: HYPERTENSION BP Assessed: Y/N Pre-Exercise BP: ................................................................................................................... Effective Control: Effective Control: Y/N Y/N Advice Given: ............................... .................................. Salt Intake Discussed: Y/N ..................................................... / Irreg............................ ................. .............................................................................. ............................................................................ ...... HBA1C:.................. Good Control: Y/N ................................................................................................... .................................................

........................ATTENDANCE / APPOINTMENT INFORMATION NAME: .................5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 12 of 14 ........................................ 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 1 Understanding Heart Disease Physical Activity Stress and Relaxation 2 Medications Healthy Eating and Food Labelling CBT CRF v4...................................................................

.............................. TRH 40% ................. 13 of 14 ................................ MODERATE HRR .......... PROGRESS (since discharge – note any symptoms) If surgical 12 weeks since op: CURRENT PA (FITT) and advice given GTN On Person? Guidelines? Y Y Y N N N Y N PREVIOUS PA EXERCISE LIMITATIONS ADAPTIONS TO EXERCISE POSSIBLE MEDS SIDE EFFECTS / PA CONSIDERATIONS PATIENT CONCERNS PATIENT GOALS ADDITIONAL COMMENTS Actual / Predicted MRH . Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 DATE .............. BB? 70% ........................................................................................................................................CARDIAC REHABILITATION EXERCISE ASSESSMENT NAME ............. CRF v4...... HIGH Comments: Permission required Y N Permission received Y N CHECKLIST Discussed with Patient Up to 10 Weeks? Y N Effort score? Y N Sensible Precautions? Y N Safety advice? Y N Warm up / Cool down? Y N Exercise book given? Y N Home exercise? Y N EP INITIALS ................................. EXERCISE START DATE ................ 50% .......................... RHR ....................... RISK STRATIFICATION LOW 60% ............. Grad Date .5Pathway Oct2011 SIGNATURE .... 80% ......... AGE ....

...................................................................................................................................................................................................................................................... (Borg 0-10 scale) Independent Exercise Limitations During Exercise: ....... Plan For Future Exercise Exercise Level Achieved: ... Graduated: If No reason for Discharge: .... No Regular Exercise .......................................................................5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 14 of 14 ........... CRF v4.bpm Exercise Referral Scheme Target HR: ....................................................................... Finish / Discharge Date: ........................ of Sessions Attended ............................................ Sent To: .......................SUPERVISED EXERCISE PROGRAMME Site: Horton / Abingdon / BBL / Witney Start Date: ...... mins Phase IV Exercise HR Achieved: ............................... Y/N No........... % of Gym Attendance ............................................................................................ Referral Form Required: Y/N Referral Form Completed: ......................................................................................bpm Independent Gym Working at RPE: .