PLACE LABEL HERE
Outpatient Follow-up Care Plan
Cardiac Wellness Program
Dr: ______
Your patient: ______DOB: ______
Diagnosis: rMI rCABG rPCI rStable Angina
rValve replacement/repair rPacemaker/ICD rOther: ______
Date of diagnosis: ______
Progress toward treatment goals:
r Increase functional capacity
A. Initial MET level: ___ Current MET level: ___ % change ___
B. Home exercise program initiated: ___
r Lose weight/reduce BMI
A. Initial weight: ____ Current weight: ____ % change ____
B. Is participating in a nutrition and exercise program, which promotes weight loss? ___
C. Understands the components of a healthy, weight reduction diet including:
rCounting Kcals
rPortion Control
rAware of fat intake
rIncreasing healthy food choices
rDecreasing high fat food choices
D. Practices the following behaviors:
rCounts Kcals
rFollows home exercise program
rIdentifies food triggers
r Manage lipid levels
A. Knows their current results? _____
B. Identifies a plan to optimize lipid management to include nutrition, exercise, and appropriate use of medications if necessary? _____
C. Identified need to see a dietician? _____
D. Continues medical follow up addressing lipid control with Physician? _____
r Manage hypertension
A. Knows BP and treatment goals? _____
B. Compliant with medications? _____
C. Compliant with nutrition and exercise routine? _____
D. Continues medical follow up addressing BP control with Physician? _____
r Manage stress and/or depression:
A. Identifies personal stressors? _____
B. Identifies signs/symptoms of stress? _____
C. Identifies methods of stress management and relaxation? _____
D. Psychosocial referral recommended/initiated? _____
*2-40017* FORM 2-40017 INITIATED 04/2011 Page 1 of 2
PLACE LABEL HERE
Outpatient Follow-up Care Plan
Cardiac Wellness Program
r Manage diabetes. FBG _____ HbA1C _____ Date______
A. Current FBG? _____
B. Knows results of most recent HbA1C? _____
C. Monitors FBG as ordered by Physician? _____
D. Lifestyle modifications made to optimize blood sugar levels? _____
E. Knows signs/symptoms of Hypoglycemia and appropriate treatment? _____
F. Knows when to contact the Physician with abnormal BS results? _____
G. Knows the relationship between medications, nutrition, and exercise in treating Diabetes? _____
H. Continues medical follow up addressing BS control with Physician? _____
I. CDE/nutritionist referral recommended/initiated? _____
r Quit smoking
A. Quit smoking? _____; If not, how many per day? _____
B. Continued smoking cessation? _____
r Return to work
A. Returned to work? _____
r Return to daily activities
A. Return to daily activities? _____; If not, why? ______
______
Date Time Staff signature
r I agree with the individualized care plan and exercise prescription and do not require any changes at this time.
r I would like to change the following: ______
______
______
______
______
______
Date Time Physician Signature PID Number
FORM 2-40017 INITIATED 04/2011 Page 2 of 2