National Heart Failure Audit Pro Forma v3.0 (word version)
Last updated 18/04/2013 by Polly Mitchell
Hospital name
Patient details
*Local patient identifier (CRN)
NHS Number:
*Patient forename
*Patient surname
*Date of birth
dd / mm / yyyy
*Gender
Male / Female
*Postcode (of usual address)
Admission details
*Date of admission
dd / mm / yyyy
1. No limitation of physical activity
2. Slight limitation of ordinary physical activity
*Breathlessness (on admission)
3. Marked limitation of ordinary physical activity
4. Symptoms at rest or minimal activity
9. Unknown
*Previous IHD
Yes / No / Unknown
*Previous AMI
Yes / No / Unknown
*Previous asthma
Yes / No / Unknown
*Previous CODP
Yes / No / Unknown
*Previous value disease
Yes / No / Unknown
*Previous hypertension
Yes / No / Unknown
*Previous diabetes
Yes / No / Unknown
Height (cm)
Weight (kg) (last recorded)
0. No
1. Mild
*Peripheral oedema (on admission)
2. Moderate
3. Severe
9. Unknown
Heart rate (bpm) (last recorded)
Blood pressure (mmHg) (last recorded)
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National Heart Failure Audit Pro Forma v3.0 (word version)
Last updated 18/04/2013 by Polly Mitchell
BNP (pg/ml) (last recorded)
NT pro BNP (pg/ml) (last recorded)
Hb (g/dL) (last recorded)
Urea (mg/dL) (last recorded)
Creatinine (mmol/L) (last recorded)
Electrolytes Na (mEq/L) (last recorded)
Electrolytes K (mEq/L) (last recorded)
1. Sinus rhythm
2. Atrial fibrillation
3. LBBB
*ECG (last recorded)
4. Previous MI
6. Not done - planned after discharge
7. Not done - not yet planned
8. Other
9. Unknown
QRS duration (ms)
0. Normal
1. LV systolic dysfunction
2. LV hypertrophy
3. Valve disease
*Echo (last recorded)
4. Diastolic dysfunction
6. Test not done - planned after discharge
7. Test not done - not yet planned
8. Other
9. Unknown
0. No
1. Captopril
2. Enalpril
3. Lisinopril
4. Perindopril
5. Ramipril
*ACE Inhibitor (discharge)
6. Trandolapril
7. Other ACEI
8. Not applicable
9. Unknown
10. Drug therapy stopped
11. Contraindicated
12. Declined by patient
ACE Inhibitor dose (mg/day)
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National Heart Failure Audit Pro Forma v3.0 (word version)
Last updated 18/04/2013 by Polly Mitchell
0. No
1. Candesartan
2. Losartan
3. Valsartan
*ARB (discharge)
4. Other ARB
8. Not applicable
9. Unknown
10. Drug therapy stopped
11. Contraindicated
12. Declined by patient
ARB dose (mg/day)
0. No
1. Bisoprolol
2. Carvedilol
3. Nebivolol
*Beta blocker (discharge)
4. Other Beta blocker
8. Not applicable
9. Unknown
10. Drug therapy stopped
11. Contraindicated
12. Declined by patient
Beta blocker dose (mg/day)
0. No
1. Bumetanide
2. Ethancrynic acid
3. Furosemide
4. Torasemide
*Loop diuretic (discharge)
5. Other loop diuretic
8. Not applicable
9. Unknown
10. Drug therapy stopped
11. Contraindicated
12. Declined by patient
Loop dose (mg/day)
0. No
1. Eplerenone
2. Spironolactone
*MRA (discharge)
3. Other ARA
8. Not applicable
9. Unknown
10. Drug therapy stopped
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National Heart Failure Audit Pro Forma v3.0 (word version)
Last updated 18/04/2013 by Polly Mitchell
11. Contraindicated
12. Declined by patient
MRA dose (mg/day)
0. No
1. Bendroflumethazide
2. Metolazone
3. Other thiazide
*Thiazide diuretic (discharge)
8. Not applicable
9. Unknown
10. Drug therapy stopped
11. Contraindicated
12. Declined by patient
Thiazide dose (mg/day)
0. No
1. Yes
8. Not applicable
*Digoxin (discharge)
9. Unknown
10. Drug therapy stopped
11. Contraindicated
12. Declined by patient
Digoxin dose (mg/day)
0. None
1. CRT-D
*Previous device therapy (during this or
previous admission)
2. CRT-P
3. ICD
4. PM
12. Declined by patient
*Confirmed diagnosis of heart failure
Yes / No / Unknown
*Did the patient die?
Yes / No
*Date of discharge or death
dd / mm / yyyy
*Referral to heart failure liaison service
Yes / No / Unknown
*Referral to palliative care
Yes / No / Unknown
*Referral to care of the elderly services
Yes / No / Unknown
*Referral to cardiology follow-up
Yes / No / Unknown
*Referral to GP
Yes / No / Unknown
*Referral to cardiac rehab
Yes / No / Unknown
*Main place of care
1. Cardiology
2. General Medicine
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National Heart Failure Audit Pro Forma v3.0 (word version)
Last updated 18/04/2013 by Polly Mitchell
3. Other
9. Unknown
1. Consultant cardiologist
2. Other consultant with interest in HF
*Which of the following did the patient
see?
3. HF Specialist nurse
4. Other
9. Unknown
*Did the patient receive input from a
multidisciplinary HF team?
Yes / No / Unknown
1. A heart failure pre-discharge management plan is in place
2. A heart-failure management plan has been discussed with the
patient
*Discharge planning
3. A heart failure management plan has been communicated to the
primary care team
4. All of the above
5. None of the above
9. Unknown
*Was the patient stable on oral therapy
after discharge planning?
Yes / No / Unknown
*Was a review appointment with the
specialist multidisciplinary HF team made?
Yes / No / Unknown
Date of heart failure review appointment
dd / mm / yyyy
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