Name:

HEART FAILURE QUERY FOR SPECIFICITY PROGRESS NOTE Attention: _______________________________________

MRN:

Heart Failure is documented in this medical record. Specify the type and acuity of heart failure below and include the specific diagnosis in your following progress notes or addendums. Refer to the tables below for information required for specificity. Additional notes are below: ________________________________________________________________________________ ________________________________________________________________________________
Step 1: Select a specific Heart Failure Diagnosis:
Acute Systolic Heart Failure Acute on Chronic Systolic Heart Failure Chronic Systolic Heart Failure Acute Combined Systolic and Diastolic Heart Failure Acute-on-Chronic Combined Systolic and Diastolic Heart Failure Chronic Combined Systolic and Diastolic Heart Failure Other (specify diagnosis)______________________________________________________________________________ Not able to be determined Acute Diastolic Heart Failure Acute-on-Chronic Diastolic Heart Failure Chronic Diastolic Heart Failure

Step 2: Select any co-morbid or complicating conditions (possible, probable, suspected, rule out, are acceptable diagnostic terms)
Cardiomyopathy (specify type) ________________________________________ Rheumatic Heart Disease Mitral Valve Stenosis Mitral Valve Insufficiency Aortic Valve Stenosis Aortic Valve Insufficiency Acute Exacerbation of Cor Pulmonale Chronic Cor Pulmonale Hypertensive Heart Disease Hypertension Arrhythmia-Induced Heart Failure (specify Arrhythmia) ______________________________________________ Other/unable to determine:

Reference Chart for Heart Failure:

Systolic: Diastolic: Evidence of reduced extent of contraction during Evidence of diastolic dysfunction on echo systole resulting in systolic dysfunction Evidence of normal systolic function with an EF>50% during a heart EF<40-50% (sometimes called left sided heart failure) failure event (sometimes called right sided heart failure) Left ventricular dilation & Low cardiac output Concentric left ventricular hypertrophy & abnormal diastolic filling Acuity: Acute (typically first event) Acute on Chronic decompensated (exacerbation or subsequent acute events) Chronic compensated (maintenance w/ Digoxin, ACE, ARB, Ca+ channel blockers, diuretics, nitrates, blockers)

CMS Process of Care Core Measure Reminder (http://hospitalcompare.hhs.gov):

Heart Failure Patients Given Discharge Instructions Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)(or contraindication documented) Heart Failure Patients Given Smoking Cessation Advice/Counseling

Document any additional information as an addendum to your existing note or as a new note in the chart.
Indicate on this form if no additional information is applicable. MD Signature_____________________________________ ID#

_________ Date__________ Time _________

Date of Review: ________,_______,_______ Coder Initiated Query: Yes No Initials: ________

Copyright, 2012 by Mark Dominesey Permission to reproduce is granted with this copyright notice intact