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CHF Flow Sheet: Baylor/Agape Outreach

Patient Name:

Instructions: Complete flow sheet. Answers indicating presence of problem should be circled, further explored, and if significant, SOAPed. Update medication list with complete information (include prescriber's name) and determine if patient is compliant.

Parameter (initial by date)	Date/	.Date/	Date/	Date/
Medications: Compliant? Y/N List below	.	.	.	.
General	.	.	.	.
Chest pain (signif CHF)	.	.	.	.
Feel better/worse than last visit	.	.	.	.
Appetite >/=/<	.	.	.	.
Sleep	.	.	.	.
Fatigue/tired (signif CHF)	.	.	.	.
fever/chills	.	.	.	.
Weight change (signif CHF)	.	.	.	.
Specific to CHF (+/-)	.	.	.	.
Dyspnea @ rest	.	.	.	.
DOE (distance)	.	.	.	.
Nocturia (# times/night)	.	.	.	.
Orthopnea/# pillows	.	.	.	.
PND	.	.	.	.
Cough - worse recumbent? > night?	.	.	.	.
JVD	.	.	.	.
Lung sounds - describe	.	.	.	.
Edema (shin 4 seconds)	.	.	.	.
Self-Management (=/-/# times/week)	.	.	.	.
BP checks/week (recorded)	.	.	.	.
Verbalizes target (<135/85)	.	.	.	.
Weights/week (recorded)	.	.	.	.
Last recorded weight	.	.	.	.
Verbalizes specific < Na diet	.	.	.	.
Exercise: # days/week & minutes/session	.	.	.	.
Alcohol specific < 2 day	.	.	.	.
Smoking habits	.	.	.	.
BP today R/L	.	.	.	.
AP/Resp	.	.	.	.

List Medications (note if using back of sheet. Include dose, frequency, doctor/NP)