pPCI CARDIAC REHABILITATION ASSESSMENT

PATIENT DETAILS

DOB:

GP DETAILS

Unit No.:

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

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

Tel Nos: .........................................................

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

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

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

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

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: ......................................................................................................................................

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

CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

1 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 v4.5Pathway 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

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 Economic
Group:

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:
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

3 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 v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

4 of 14

MEDICATION RECORD
Known Allergies:- ................................................................................................
DATE

DATE

DATE

DATE

Name & Dose

Name & Dose

Name & Dose

Name & Dose

DRUG GROUP

Beta Blockers

Bisoprolol ...... mg

Bisoprolol ....... mg

Bisoprolol ....... mg

Bisoprolol ...... mg

Atenolol

...... mg

Atenolol

....... mg

Atenolol

....... mg

Atenolol

...... mg

Ramipril

...... mg

Ramipril

....... mg

Ramipril

....... mg

Ramipril

...... mg

ACE Inhibitor
A2 Antagonist
Statin / Fibrates

Atorvastatin ..... mg

Atorvastatin ...... mg

Atorvastatin ...... mg

Atorvastatin ..... mg

Simvastatin ...... mg

Simvastatin ...... mg

Simvastatin ...... 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

..................mcg

.................. mcg

.................. mcg

.................. mcg

Diuretics

Nitrate
GTN Spray/Tabs
Pre-admission
Medies

CRF v4.5Pathway Oct2011

Others:-

Oxford University Hospitals NHS Trust

Others:-

To be Reviewed Oct 2012

Others:-

Others:-

5 of 14

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: .....................................................................

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

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

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

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

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

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

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

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

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

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

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:.....................................................................

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

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

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

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

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. do Activity:

Safe:

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

2: Does Pt sweat during activity:
Often

Sometimes

3: Does pt. do 30 mins Activity

5 times per week:

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

Never / Rarely

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

Y/N

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

..................................................................................
Safe Levels of Activity
Post Discharge Discussed:

Y/N

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

Y/N

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

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

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

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: ...................................................................
Smoke Within 30 mins. of Waking: ..................Y / N
Smoking Cessation support offered: ................Y / N
Referred to PN

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

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

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

Y/N

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

Smoking Cessation support offered: ............... Y / N
Referred to PN

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

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

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

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

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

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

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

CRF v4.5Pathway Oct2011

Weekly: ..................

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

6 of 14

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: .....................................................................
..................................................................................

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

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

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

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

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

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

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

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: ...............................................................

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

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

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

ACTIVITY

NYHA Class I / II / III / IV

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

2: Does Pt sweat during activity:

Sometimes

3: Does pt. do 30 mins Activity

5 times per week:

NYHA Class I / II / III / IV

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

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

Often

ACTIVITY

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

2: Does Pt sweat during activity:
Often

Never / Rarely

Sometimes

3: Does pt. do 30 mins Activity

5 times per week:

Y/N

Never / Rarely
Y/N

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

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

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

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

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

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

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

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

..................................................................................
Role of Exercise in
Prevention of CHD Discussed:
Y/N

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

SMOKING ASSESSED

SMOKING ASSESSED

Y/N

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

Never
Current
Is Ex-Smoker of > 1 Month:

Y/N

Never
Current
Is Ex-Smoker of > 1 Month:

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

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

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

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

Referred to PN

Referred to PN

Quit form sent

Quit form sent

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

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

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

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

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

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

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

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

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

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

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

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

CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

7 of 14

IN PATIENT ASSESSMENT

pPCI FOLLOW UP CLINIC

Date:

Date:

PSYCHOLOGICAL STATE ASSESSED

Y/N

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

Dartmouth Co-op:
Y/N
History of Anxiety and Depression
Y/N
Psychological support offered
Y/N
Concerns voiced:......................................................
..................................................................................
..................................................................................
..................................................................................
Sexual concerns assessed
Sexual Counselling offered

Y/N
Y/N

PSYCHOLOGICAL STATE ASSESSED

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

Psychological support offered
Y/N
Referred for Psychological Counselling Y / N
Comments: ..............................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
Sexual concerns assessed
Sexual Counselling offered

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

Cholesterol Assessed
Hx of Chol:

Y/N

Y/N
Y/N

.................................................................................
Return to Work Discussed
Y/N
.................................................................................
.................................................................................
.................................................................................
Interested in information sessions

DIET/WEIGHT MANAGEMENT

Y/N

Y/N

DIET/WEIGHT MANAGEMENT
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: ...............................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
ALCOHOL ASSESSED

Y/N

.................................................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
ALCOHOL ASSESSED

Y/N

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

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

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

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

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

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

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

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

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

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

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

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

CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

8 of 14

CARDIAC REHABILITATION ASSESSMENT

Date:
PSYCHOLOGICAL STATE ASSESSED

Y/N

END ASSESSMENT
Date:
PSYCHOLOGICAL STATE ASSESSED

Y/N

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

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

Psychological support offered

Y/N
Referred for Psychological Counselling Y / N

Psychological support offered

Y/N
Referred for Psychological Counselling Y / N

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

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

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

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

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

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

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

Sexual concerns assessed

Sexual Counselling offered

Sexual concerns assessed

Sexual Counselling offered

Y/N
Y/N

Y/N
Y/N

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

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

Return to Work:

Y/N

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

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

Full time / Part time / Planned / Unplanned /

Unemployed / Looking for work / Temporarily sick /
Awaiting further investigation / HGV awaiting ETT .

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

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

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

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

DIET/WEIGHT MANAGEMENT
Cholesterol Assessed

DIET/WEIGHT MANAGEMENT
Cholesterol Assessed

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

Y/N

Y/N

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

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

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

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

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

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

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

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

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

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

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

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

BMI Assessed:

Y/N

BMI Assessed:

Y/N

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

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

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

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

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

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

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

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

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

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

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

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

..................................................................................
ALCOHOL ASSESSED

Y/N

ALCOHOL ASSESSED

Y/N

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

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

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

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

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

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

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

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

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

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

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

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

CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

9 of 14

IN PATIENT ASSESSMENT

pPCI FOLLOW UP CLINIC

Date:

Date:

HYPERTENSION

BP Assessed:

Y/N

HYPERTENSION

BP Assessed:

Y/N

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

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

Treated:
Good Control:
Salt Intake Discussed:

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

Y/N
Y/N
Y/N

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

..................................................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
DIABETES
Type I
Type II

Blood Sugars Assessed:

Y/N

.................................................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
DIABETES

Blood Sugars Assessed:

Y/N

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

Diet
Tabs
Insulin

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

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

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

HbA1C ......................................................................
Previous Control: ......................................................
Newly Diagnosed:

Y/N

..................................................................................
..................................................................................
..................................................................................
..................................................................................
Assessed:

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

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

FAMILY HISTORY

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

Y/N

.................................................................................
.................................................................................
.................................................................................
HbA1C .....................................................................
Referred to PN / OCDEM:
FAMILY HISTORY

Y/N
Assessed:

Y/N

Mother: .....................................................................

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

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

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

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

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

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

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

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

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

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

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

CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

10 of 14

CARDIAC REHABILITATION ASSESSMENT

Date:
HYPERTENSION

BP Assessed:

Y/N

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

END ASSESSMENT
Date:
HYPERTENSION

BP Assessed:

Y/N

Pre-Exercise
BP: .................... HR: ............ Reg. / Irreg. ..............

Good Control:

Y/N

Salt Intake Discussed:

Y/N

Post-Exercise

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

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

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

Good Control:

Y/N

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

Salt Intake Discussed:

Y/N

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

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

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

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

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

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

DIABETES

Blood Sugars Assessed:

Y/N

DIABETES

Blood Sugars Assessed:

Y/N

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

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

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

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

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

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

Effective Control:

Effective Control:

Y/N

Y/N

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

11 of 14

ATTENDANCE / APPOINTMENT INFORMATION

NAME: ..................................................................................................................................................
Patient has dates for the Information Sessions:

Y/N

Horton Information Sessions

Week

Topic

Date

Healthy Eating

Understanding Heart Disease

Emergency First Aid

Pharmacist and Blood Pressure

Risk Factor Summary

Physical Activity and Heart Disease

An Introduction to Relaxation

Managing Day to Day Stresses

JR Information Sessions
Week

Topic

Date

Understanding Heart Disease

Physical Activity
Stress and Relaxation

Medications
Healthy Eating and Food Labelling
CBT

CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

12 of 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
On Person?
Guidelines?

Y
Y
Y

N
N
N

PREVIOUS PA

EXERCISE LIMITATIONS

ADAPTIONS TO EXERCISE

POSSIBLE MEDS SIDE EFFECTS / PA CONSIDERATIONS

PATIENT CONCERNS

PATIENT GOALS

ADDITIONAL COMMENTS

Actual / Predicted
MRH .....................

RHR .................

TRH
40% ......................

50% .................

RISK STRATIFICATION

LOW

60% ..............
MODERATE

HRR ...................

BB?

70% ...................

80% ...................

HIGH

Comments:

Permission required

Permission received

CHECKLIST Discussed with Patient

Up to 10 Weeks?

Effort score?

Sensible Precautions?

Safety advice?

Warm up / Cool down?

Exercise book given?

Home exercise?

EP INITIALS ........................

CRF v4.5Pathway Oct2011

SIGNATURE .............................................................

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

DATE ............................

13 of 14

SUPERVISED EXERCISE PROGRAMME

Site: Horton / Abingdon / BBL / Witney

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

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

Graduated:

If No reason for Discharge: ....................................................

Y/N

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

............................................................................................................................................................
Referral Form Required:

Y/N

Referral Form Completed: ........................................

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

CRF v4.5Pathway Oct2011

Oxford University Hospitals NHS Trust

To be Reviewed Oct 2012

14 of 14