ࡱ> KMJ bjbj 4>ee#%<<8 4Tt.$?S _xzzzzzz$'!r^?<<v<lxx,PN,}^d0K"(K"K"Hg{ SgggdgggK"ggggggggg : Patient Name DOB MR# Date of Visit: ___ / ___ / _____ Chief Complaint: (Here to follow-up on management of chronic anticoagulation. ___________________________________________________ Current dosage of warfarin: (___mg/day, OR - *Select whether patients dosing is based on a specific day of the week, or based on a cycle (cross out extra days if cycle <7), then enter dose. * FORMCHECKBOX MondayTuesdayWednesdayThursdayFridaySaturdaySunday* FORMCHECKBOX Day 1Day 2Day 3Day 4Day 5Day 6Day 7 Recent INR Result: _____ Indication(s) for warfarin:  FORMCHECKBOX Atrial fibrillation  FORMCHECKBOX Cerebrovascular disease  FORMCHECKBOX Clotting disorder  FORMCHECKBOX Congestive heart failure  FORMCHECKBOX Deep vein thrombosis  FORMCHECKBOX Mechanical heart valve  FORMCHECKBOX Peripheral vascular disease  FORMCHECKBOX Pulmonary embolism  FORMCHECKBOX Other: _________________ Date warfarin started: __/ __/__ INR Goal range:  FORMCHECKBOX 2.0 3.0  FORMCHECKBOX 2.5 3.5  FORMCHECKBOX Other: __________ Expected Duration of Rx:  FORMCHECKBOX Indefinitely  FORMCHECKBOX 3 months  FORMCHECKBOX 3-6 months  FORMCHECKBOX Other: ___________ Medication (other than warfarin):  FORMCHECKBOX No other medication  FORMCHECKBOX See updated medication list Allergies:  FORMCHECKBOX None  FORMCHECKBOX See Summary List Plan: (Continue current dose of warfarin NEXT LAB TEST: ___/___/____ at ___ am pm (Modify dose of warfarin as noted below: F/U in office: ___ days ___ weeks ___months * Select whether patients dosing is based on a specific day of the week, or based on a cycle (cross out extra days if cycle <7), then enter dose. * FORMCHECKBOX MondayTuesdayWednesdayThursdayFridaySaturdaySunday* FORMCHECKBOX Day 1Day 2Day 3Day 4Day 5Day 6Day 7 _________________________________ _________________________________ Signature/Professional Designation & Date Physician Signature/Professional Designation & Date     Warfarin Management Progress Note http://www.acponline.org/practiceforms History: (No complaints (Unusual bleeding (Bruising (Chest pain (Confusion (Epistaxis (Falls/injuries (Hematochezia (Hematemesis (Hematuria (Hemoptysis (Melena (Menstrual ( (Pain/swelling in LE (SOB (Other ____________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Physical Exam: VS: Wt: ____ T: ____ BP ___/ ___ P: ____ Skin: (No bruising ______________________________ Lungs: (Clear ______________________________ Card: (RRR, Nl S1S2 ______________________________ (No M,G,R _________________________ Abd: (Normal _________________________ Ext: (No edema ______________________________ (No cords ______________________________ Other: ____________________________________________ ____________________________________________ Dietary (? (Y (N Weight (? (Y (N Does patient know current dosage regimen? 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