LDL Prompt Sheet/Order Sheet

For Stroke/TIA Patients

ALLERGIES:  NKA  ASA  PENICILLIN  SULFA
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A generic equivalent drug will be dispensed when possible.
Drug information will be given unless this block is checked. 
Dear Doctor:
This patient has been identified as potentially eligible for the Stroke Performance Measure “Discharged on STATIN medication”. Please provide documentation as requested below.
Lipid Recommendations for the Prevention of Stroke in Patients with Stroke or TIA
/
Class/Level of Evidence
Ischemic stroke or TIA patients with elevated cholesterol, comorbid CAD, or evidence of an atherosclerotic origin should be managed according to NCEP III guidelines, which include lifestyle modification, dietary guidelines, and medication recommendations. / Class I, Level A
Statin agents are recommended, and the target goal for cholesterol lowering for those with CHD or symptomatic atherosclerotic disease is an LDL less than 100mg/dl. For very high risk persons with multiple risk factors the LDL goal is less than 70mg/dl. / Class I, Level A
On the basis of the SPARCL trial, administration of statin therapy with intensive lipid – lowering effects is recommended for patients with atherosclerotic ischemic stroke or TIA and without known CHD to reduce the risk of stroke and cardiovascular events. / Class I, Level B
Adams et. Al. Update to the AHAIASA Recommendations for the prevention of stroke in patients with stroke and Transient Ischemic Attack. Stroke. 2008:39.
Patient has no evidence of atherosclerosis and therefore is excluded from the measure “discharged on statin medication”.
DATE / TIME / DIET/MEDICATION/TREATMENT With Doctor’s Signature
CHOLESTEROL TREATMENT
LDL appropriate based on medical history, risk factors, and/or current treatment regimen.
Statin therapy not prescribed due to:
Allergy/Intolerance
Elevated LFT’s or active/chronic liver disease
Patient refusal
Other (Please explain):______
Please give ______mg orally daily
Low Cholesterol/Heart Healthy Diet
LFT Panel
Other:______
RBVO Dr. / RN /

Date/Time: /

Physician Signature: / Date/Time: /

458-53-1108-ID-M PMD330mw/dkf-mm-12/19/06 –Rev 11/21/08