Cardiac Rehab Physician Orders

Dr.

CARDIAC REHAB PHYSICIAN ORDERS

Name: BD: Phone: 406-

1. Diagnosis:

Covered by Medicare: NOT Covered by Medicare: (Please Indicate Diagnosis) CABG Cardiomyopathy

PTCA/Stent Arrhythmias

MI ASCHD

Stable Angina Device: Pacemaker / ICD

Heart/Lung Transplant Other: _________________

Valve surgery

Stable CHF: (LVEF 35% or less, NYHA class II to IV symptoms despite optimal heart failure therapy for at least six weeks, had no recent (≤ 6 weeks) or planned (≤ 6 months) major cardiovascular hospitalizations or procedures)

2. Date of event: /2014__

3. Risk Classification: (Indicate applicable condition)

Low Risk --- Uncomplicated MI, CABG, PTCA, Atherectomy, Stents

--- Ejection fraction > 50%

--- No ischemic changes at rest or with exercise

--- No resting or exercise-induced complex arrhythmias

--- Functional Capacity > 6 ME

Moderate Risk --- Ejection fraction 31-49%

--- Abnormal response to exercise consistent with ischemia

--- Functional capacity < 6 METS

High Risk --- Ejection fraction <30%

--- Complex ventricular arrhythmias at rest or with exercise

--- Survivor of sudden cardiac death

--- Complicated MI or Cardiac Surgery

--- Strongly positive stress test (> 2mm ST-segment depression)

--- Systolic BP falls or fails to rise with exercise

4. Develop exercise prescription using Cardiac Rehab treatment plan, (copy available upon request).

One to three individualized exercise sessions a week up to 36 sessions or more as prescribed.

5. Follow Cardiac Rehab policies & procedures consistent with KRMC emergency standing orders.

6. Other Orders/Comments: _________________________________________________________

DATE: Physicians signature:

PLEASE COMPLETE AND RETURN TO CARDIAC REHAB FAX: 751-4121 OFFICE: 751-4504

3/2014