Name
Item
Name of attending physician
text
Phone number
Item
Phone number of attending physician
integer
Admitting Diagnosis
Item
Congestive Heart Failure Associated Diagnoses
text
Diet
Item
Clear liquid
boolean
Diet
Item
AHA step 2
boolean
Diet
Item
ADA__calories
boolean
Diet
Item
Fluid restriction: 2000mL/24 hrs or __mL/24hrs
boolean
ADA specification
Item
If diet according to ADA please specify amount of calories
integer
Fluid restriction specification
Item
If fluid restriction, please specify amount per 24 hrs
integer
Activity
Item
Bed rest
boolean
Activity
Item
Bed rest with bathroom privileges
boolean
Activity
Item
Up with assistance
boolean
Acitivity
Item
Other
boolean
Specification of Other
Item
If Other, please specify
text
Nursing
Item
Vital signs every 4 hrs or per unit routine
boolean
Nursing
Item
Notify MD for: increasing dyspnea; chest pain; BP < 90/60 or > 180/110; P < 60 or > 120 bpm
boolean
Nursing
Item
Daily weights
boolean
Nursing
Item
Strict I&O
boolean
Nursing
Item
O2 via NP @2,3 or 4 L/min
boolean
Nursing
Item
Pulse ox check every 4 hrs and titrate O2 to keep pulse ox > 92%
boolean
Nursing
Item
Continuous cardiac monitoring
boolean
Medications
Item
ASA__mg PO every morning
boolean
Medications
Item
Clopidogrel 75mg PO every morning
boolean
Medications
Item
ACE inhibitor:____
boolean
Medications
Item
Lasix __ mg IVP every __hrs
boolean
Medications
Item
NTG paste ___inch(es) every__hrs
boolean
Medications
Item
Betablocker:____
boolean
Medications
Item
Digoxin (NYHA class III/IV): ___mg PO daily
boolean
Medications
Item
Spironolactone__mg PO bid
boolean
Medications
Item
Tylenol 650mg PO every 4-6 hrs prn pain
boolean
Medications
Item
MOM 30 mL PO every 12 hrs prn constipation
boolean
Medications
Item
Ambien 10 mg PO at bedtime prn for insomnia
boolean
ASA specification
Item
If ASA, please specify amount of ASA every morning
integer
ACE specification
Item
If ACE inhibitor, please specify
text
Lasix specification
Item
If Lasix, please specify amount
float
Lasix specification
Item
If Lasix, please specify frequency
integer
NTG paste specification
Item
If NTG paste, please specify amount
float
NTG paste specification
Item
If NTG paste, please specify frequency
float
Betablocker specification
Item
If Betablocker, please specify
text
Digoxin specification
Item
If Digoxin please specify amount
integer
Spironolactone specification
Item
If Spironolactone, please specify amount
integer
Item
CBC, BNP, CK, CK-MB, Troponin I, MG+, TSH, UA on admission
text
Code List
CBC, BNP, CK, CK-MB, Troponin I, MG+, TSH, UA on admission
Lab
Item
Repeat CK, CK-MB, Troponin I in 8 hrs
boolean
Lab
Item
Daily basal metabolic profile
boolean
Specification of Other
Item
If Other, please specify
text
Diagnostic Studies
Item
Echocardiogram - to be read by___
boolean
Diagnostic Studies
Item
ECG if not done in ER
boolean
Diagnostic Studies
Item
CXR:__Portable__PA/Lat, Reason: CHF
boolean
CXR specification
Item
If CXR:__, please specify
integer
CXR specification
Item
If CXR, please specify Portable__PA/Lat
integer
Patient Education
Item
Begin CHF patient education.
text
