DATA ELEMENT
D E F I N I T I O N S 2.0
February 9, 2016
Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution.
Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution
Table of Contents
Patient information
Identifying information
Sociodemographic characteristics
1
2
Cardiac Rehab Program & Timing
5
Risk Factors at Intake
13
Disease Severity Indicators at Intake
16
Program Components Delivered
18
INTAKE/DISCHARGE Values
Anthropometric, Lipid and Hemodynamic Measurements
Functional Capacity Tests
Other: Self-Report behaviours
Psycho-social Indicators
19
22
29
31
Medications
33
Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution
PATIENT INFORMATION
IDENTIFYING INFORMATION
Source Unique ID
This number is electronically generated, encrypted, and represents a unique identifier
that indicates which clinical record this patient relates to.
Unique Patient ID
Enter the patient’s permanent chart number (“patient ID number”, “hospital
number”, “chart ID”, “hospital ID”) that corresponds to the patient’s permanent
unique file number. If you are unsure which is the permanent hospital file number
ask a member of the Health Records Department staff which number is sent to the
Canadian Institute of Health Information (CIHI). This is not a “visit” number. The
CCRR automatically encrypts this number.
Data Source: Face sheet of the patient chart or on the Bradma plate stamped on the upper
right corner of most pages of the chart.
Data Entry: The HID number is institution specific and ranges between 6 and 10 digits.
Consent Given
Confirm that patient consent was obtained for data collection and analysis.
Data Entry: Choices available are:
 Yes
 No
 Unknown: ‘Not documented’
Year of Birth
Indicate the patient’s year of birth.
Unknown: ‘Not documented’
Sex
Select the patient’s sex.
Data Entry: Choices available are:
 Male
 Female
 Other (trans-sexual or hermaphrodite)
 Unknown: Not documented
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution
SOCIODEMOGRAPHIC CHARACTERISTICS
Ethnocultural Background
Refers to the ethnic or cultural group (s) to which the patient and/or their ancestors belong. An
ancestor is someone from whom a person is descended and is usually more distant than a
grandparent. Ancestry should not be confused with citizenship or nationality. Ethnic or cultural
origin refers to the ethnic “roots” of ancestral background of the population.
You may need to explain to the patient why this information is necessary. You may
choose to say “this information is collected to promote and ensure the equal
opportunity for everyone to access cardiac rehabilitation services in Canada”. The
information generated will ensure that future patients in Canada will have equal access to
services.
Data Sources: Patient intake assessment/interview.
1. Data Entry: “Indicate the patient’s ethnocultural background from the following
(multiple responses accepted): Note: for mixed ethnocultural background, select all
that apply.”(CCS definition),

Aboriginal (includes Inuit, Métis peoples of Canada, First Nations – North
American Indian)” (CCS definition),

Arab (includes Egyptian, Kuwait, Libyan) (CCS definition)

West Asian (includes Armenian, Egyptian, Iranian, Lebanese, Moroccan,
Afganistan, Assyrian and Iranian)) (CCS definition)

Black (includes African, Nigerian, Somali)(CCS definition)

Chinese

Filipino

Japanese

Korean

Latin American(includes Chilean, Costa Rican, Mexican) (CCS definition)

South Asian (includes Bangladeshi, Punjabi, Sri Lankan Bangladeshi, Sri
Lankan)

South East Asian (i.e. Cambodian, Loatian, Vietnamese, Malaysian) (CCS
definition)

White/Caucasian

Other, if possible, specify (optional to specifiy) (CCS definition)

Unknown / Not documented
Marital Status
Select the most appropriate response that corresponds with the patient’s marital status.
Data Source: Face sheet of the patient chart, Admission history, History and Physical,
Nursing Admission note, hospital information system, Intake Assessment
Data Entry: Choices available are:
 Single
 Married or equivalent (i.e.: common law, same sex)
 Divorced
 Widowed
 Separated or equivalent
 Unknown: Not documented
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Language Preference
Refers to the patient’s preference to communicate in one of Canada’s two official
languages (English or French).
Data Entry: Choices available are:
 English
 French
 Other
 Unknown: Not documented
Education
Indicate the highest level of education the patient has attained:
Data Source: Admission history, intake assessment for cardiac rehabilitation.
Data Entry:
 Less than High School (CCS definition) – patient did no complete all high
school requirements and no Secondary School Diploma was awarded (or
equivalent).
 High School – patient completed high school and Secondary School Diploma
was awarded (or equivalent).
 Trades certificate (CCS definition)
 College certificate or diploma (a certificate from a community college,
CEGEP, school of nursing, theological college or private college) (CCS
definition)
 University (a certificate below the bachelor level, bachelor’s degree,
certificate above the bachelor level, master’s degree, earned doctorate or a
professional degree in medicine, dentistry, veterinary medicine or optometry)
 Unknown: Not documented
Support Structure
Select the most appropriate response that corresponds with the patient’s living situation.
Data Source: Face sheet of the patient chart, Admission history, History and Physical,
Nursing Admission note, hospital information system, Intake Assessment
Data Entry: Choices available are:
 Lives alone – patient is living alone.
 Lives with Spouse/Partner – patient is currently living with a spouse or partner
(married, common-law, same sex or equivalent)
 Lives with Friends/Family – patient is living with others that does not include
a spouse or partner. This could include children, parents, in-laws.
 Other
 Unknown: Not documented
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution
Job Classification
Ask the client to describe the degree of force exerted in their job.
The job classifications options are taken from the U.S. Department of Labor's Dictionary
of Occupational Titles, and are comparable to those classifications as found in the
National Occupational Classification Career Handbook (NOC-CH;
http://www.wcb.ab.ca/providers/addgjob.asp).
Data Entry: Choices available are:
 SEDENTARY WORK - Exerting up to 10 pounds of force occasionally and/or a
negligible amount of force frequently or constantly to lift, carry, push, pull or
otherwise move objects, including the human body. Sedentary work involves sitting
most of the time, but may involve walking or standing for brief periods of time. Jobs
are sedentary if walking and standing are required only occasionally and all other
sedentary criteria are met.
 LIGHT WORK - Exerting up to 20 pounds of force occasionally and/or up to 10
pounds of force frequently, and/or negligible amount of force constantly to move
objects. Physical demand requirements are in excess of those for sedentary
work. Light work usually requires walking or standing to a significant
degree. However, if the use of the arm and/or leg controls require exertion of forces
greater than that for sedentary work, and the worker sits most of the time, the job is
rated light work.
 MEDIUM WORK - Exerting up to 50 pounds of force occasionally, and/or up to 20
pounds of force frequently, and/or up to 10 pounds of force constantly to move
objects.
 HEAVY WORK - Exerting up to 100 pounds of force occasionally, and/or up to 50
pounds of force frequently, and/or up to 20 pounds of force constantly to move
objects.
 VERY HEAVY WORK - Exerting in excess of 100 pounds of force occasionally,
and/or in excess of 50 pounds of force frequently, and/or in excess of 20 pounds of
force constantly to move objects
 Not applicable – patient does not work, or is not going back to work
 Unknown: Not documented
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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CARDIAC REHAB PROGRAM & TIMING
Hospital Discharge Date
Enter the day, month and year the patient was discharged from hospital.
Data Entry:
 Not applicable if patient referred following outpatient visit or for stable disease.
 “Not documented” / unknown
Referral Diagnosis
The referral diagnosis refers to the most recent diagnosis preceding the patient’s referral to
cardiac rehabilitation. This item does not include interventions or procedures.
There may be more than one possible referral diagnosis reported if the second referral
diagnosis occurred within the same hospitalization period. The following are possible
scenarios:
1. If the patient had coronary artery bypass graft surgery with an aortic valve
replacement then both CABG and AVR would be considered referral diagnoses.
2. If patient had an MI, was referred for cardiac rehabilitation and had another event
during the period between referral and intake, the MI would count as the referral
diagnosis and the secondary event would be listed as a secondary referral diagnosis.
Data Source: Patient’s chart, referral form, health professional referral letter, patient
intake interview.
Data Entry: Choices available are:
 Stable CAD / Angina
 Acute coronary syndrome (ACS) – Unspecified
 Acute coronary syndrome (ACS) - Myocardial infarction - Unspecified
 Acute coronary syndrome (ACS) - Myocardial infarction - STEMI
 Acute coronary syndrome (ACS) - Myocardial infarction - Non STEMI
 Acute coronary syndrome (ACS) - Unstable Angina
 Heart Failure - Unspecified
 Heart Failure - Cardiomyopathy
 Cerebral vascular disease - Unspecified
 Cerebral vascular disease - TIA
 Cerebral vascular disease - Stroke
 Peripheral Vascular disease
 High-Risk Primary Prevention
 Arrhythmia – unspecified
 Arrhythmia – atrial fibrillation
 Arrhythmia – ventricular tachycardia
 Arrhythmia - other


Other
Unknown: Not documented
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution
Referral Procedure(s)
Did the patient undergo a procedure associated with the referral diagnosis(es)? Choose all
that apply.
Data Source: Patient’s chart
Data Entry: Choices available are:
 Yes – please specify:
o Percutaneous coronary intervention (PCI)
o Bypass surgery – CABG
o Heart Transplant
o Valve surgery
o Percuteneous valve intervention
o VADs
 Device insertion (e.g., CRT, ICD, Pacemaker)
o Ablation
o Other
 No
 Unknown: Not documented
Referral Diagnosis(es)/Procedure(s) Date(s)
Enter the date(s) of the diagnosis(es), If there is more than one date as in scenario #2 above,
enter a date for each event selected. However, the date corresponding to the most recent
referral event will be considered the Referral Diagnosis Date. If the patient did not have an
event recently, but a procedure, enter the procedure date.
Data Source: Face sheet of the patient chart, hospital information system,
nursing admission note, physician referral note, history and physical, or
cardiac rehabilitation intake interview.
Data Entry:
o Not applicable – patient referred for stable disease or high-risk primary
prevention
o Unknown: ‘Not documented’
History of cardiac event(s)
Does the patient have a history of cardiac events? Choose all that apply. Enter
dates for each.
 Data Source: Patient’s chart, referral form, health professional referral letter,
patient intake interview.
 Data Entry: Choices available are:
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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o Yes:

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










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Stable CAD/Angina
Acute coronary syndrome (ACS) – Unspecified
Acute coronary syndrome (ACS) – Myocardial infarction Unspecified
Acute coronary syndrome (ACS) – Myocardial infarction – STEMI
Acute coronary syndrome (ACS) – Myocardial infarction – NonSTEMI
Acute coronary syndrome (ACS) – Unstable Angina
Heart Failure - Unspecified
Heart Failure – Cardiomyopathy
Cerebral vascular disease - Unspecified
Cerebral vascular disease - TIA
Cerebral vascular disease - Stroke
Peripheral Vascular disease
High Risk Primary Prevention
Arrhythmia – unspecified
Arrhythmia – atrial fibrillation
Arrhythmia – ventricular tachycardia
Arrhythmia - other
other
o No
o Unknown: Not documented
History of cardiac procedure(s)
Does the patient have history of cardiac procedure(s)? Choose all that apply. Enter dates
for each.
Data Source: Patient’s chart
Data Entry: Choices available are:
 Yes, please list: - need date field associated with this
o Percutaneous intervention (PCI)
o Bypass surgery – CABG
o Heart transplant
o Valve surgery
o Percutenous Valve insertion
o Ablation
o VADs
o Device (e.g., CRT, ICD, Pacemaker)
 No
 Other
 Unknown: Not documented
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Comorbidities
Does the patient have a diagnosis of any of the following conditions? Choose all that
apply
Data Source: Patient’s chart, referral form, health professional referral letter,
patient intake interview.
Data Entry: Choices available are:
 Arthritis
 Musculoskeletal pain
 Hip or knee replacement
 Cancer
 Osteoporosis
 Renal disease
 Liver disease
 Pulmonary disease
 Infectious disease
 Other
 No
 Unknown / not documented
Referral Location
Where did the referral come from?
Data Source: Patient’s chart
Data Entry: Choices available are:
 In-patient unit
 Outpatient visit [ambulatory clinic/MD office]
 Emergency room
 Cardiac diagnostics / Intervention


Other
Unknown / Not documented
Type of Referring Provider
Enter the type of provider who signed the referral form.
Data Entry: Choices available are:
 Cardiologist
 Cardiovascular surgeon
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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



Primary care physician
Nurse-practitioner
Other
Unknown: Not documented
Referral Date
Enter the date the CR referral document was signed by a physician. For patients
referred from an inpatient care team, this may be the date of the discharge orders.
Data Source: Face sheet of the patient’s chart, referral form at the CR program,
others as
indicated.
Data Entry: Enter a date.
Unknown: ‘Not documented’
Referral Receipt Date
Enter the date the patient referral is received by the program.
Data Source: Face sheet of the patient’s chart, referral form at the CR program,
date
received stamped or fax date on referral form, others as indicated.
Data Entry: Enter a date.
Unknown: ‘Not documented’
Automatic Referral
Was this referral initiated automatically?
Data Entry: Choices available are:
 Yes
 No
 Unknown: ‘Not documented’
Patient Enrolment
CR Program enrollment is defined as patient attendance at any first CR program visit.
Please note that all referred patients should be entered in CCRR so that we can assess the
proportion of referred patients enrolling (CR quality indicator). For those patients who do
not enroll, please complete all available information from their referral form. It is hoped
that sex, year of birth, hospital discharge date, referral diagnosis, referral procedure,
referral diagnosis / procedure date, referral location, type of referring provider, referral
date, referral receipt date, and automatic referral variables could be completed. Please
also record interim events and corresponding dates if applicable.
Data Entry: Choices available are:
 Yes
 No
 Unknown: ‘Not documented’
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Intake Visit Date
Enter the date the patient attended the first appointment at the CR program (this
may
be the intake assessment, rehabilitation exercise test, educational class, or other
services)
Data Source: Patient’s chart.
Data Entry: Enter a date.
Unknown: ‘Not documented’
Program Model
Enter the type of program in which the patient is participating. This does not refer to
maintenance programs.
Data Source: Patient’s chart.
Data Entry:
 Supervised program in a clinical setting (e.g., traditional hospital-based program)
 Home-based (i.e., includes intake assessment, comprehensive CR elements with
monitoring by phone or email, and formal re-assessment at program completion)
 Community-based (supervised exercise in a community setting)
 Web-based or mobile phone
 Other
 Unknown / not documented
Travel Time to Rehab
Enter the estimated time for a one-way trip using the form of transportation
available and to be used most often by the patient to access cardiac
rehab.
Data Source: Cardiac rehabilitation intake interview/ assessment.
Data Entry: Choices available are:
 0-30 minutes
 31-45 minutes
 46-60 minutes
 > 60 minutes
 Unknown: Not documented
Date the CR Program Began
Enter the date the patient officially began the exercise portion of the cardiac rehabilitation
program. Please note that this applies to both on and off-site (home-based) cardiac
rehabilitation programs.
Unknown: ‘Not documented’
Interim Event(s)
List any cardiac event(s) that occurred after referral to and prior to discharge from
cardiac rehabilitation. Multiple post-referral events are possible.
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Data Source: Patient’s chart, physician progress note/assessment, nursing
intake assessment note, hospitalization record(s), patient report (must followup with primary care physician to validate).
Data Entry: Choices available are:
 Yes, please choose all that apply:
o Acute coronary syndrome (ACS) – Unspecified
o Acute coronary syndrome (ACS) - Myocardial infarction –
Unspecified
o Acute coronary syndrome (ACS) - Myocardial infarction –
STEMI
o Acute coronary syndrome (ACS) - Myocardial infarction - Non
STEMI
o Acute coronary syndrome (ACS) - Unstable Angina
o Cerebral vascular disease - TIA or stroke
o Other
o Death – Cardiac
o Death - Non Cardiac
 No, patient had no interim event
 Unknown: Not documented
Interim Event(s) Date(s)
Date(s) of cardiac event(s) occurring after referral to and prior to discharge from
cardiac rehabilitation.
Data Source: Patient’s chart, physician progress note/assessment, nursing intake
assessment note, hospitalization record(s), patient report (must follow-up with
primary care physician to validate).
Unknown: ‘Not documented’
Not applicable (no interim event)
Interim cardiac procedure(s)
Did the patient have cardiac procedure(s) occurring after referral to and prior to discharge
from cardiac rehabilitation? Choose all that apply. Enter dates for each.
Data Source: Patient’s chart
Data Entry: Choices available are:
 Yes, please check all that apply
o Percutaneous intervention (PCI)
o Bypass surgery – CABG
o Valve surgery
o Percutaneous valve procedure
o Device insertion (e.g., CRT, ICD, Pacemaker)
o Ablation
o VADs
o other
 None
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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
Not documented
Premature Termination(s)
Premature termination refers to the instance where patients do not complete their
prescribed exercise sessions or other core components of the program. Indicate
the reason for premature termination of the patient's cardiac rehab program, if
applicable.
Data Entry: Choices available are:
 Lost to follow-up (patient stopped coming and could not contact them)
 Patient choice (quit)
 Relocation
 Return to work
 Event – Cardiac
 Event – Other health problem
 Death
 Patient met goals early
 Not applicable – patient completed program
 Other
 Not documented
Premature Termination(s) Date
If applicable, enter the date that patient prematurely terminated participation in
the program.
Include Not applicable to indicate that the patient did not premature terminate the
CR program.
Unknown: ‘Not documented’
CR Program Completion
To complete the CR program a patient must have attended at least some of the CR
intervention components and also have completed a formal re-assessment by the
CR team at the conclusion of the CR intervention. Indicate if the patient
completed the CR program.
Data Entry: Choices available are:
- Yes
- No
- Not applicable (patient had an interim event or a premature termination of the
program)
- Unknown: Not documented
Discharge Date
Indicate the date of discharge from the cardiac rehabilitation program. The
discharge date could be based on the patient completing the active CR program,
the patient completing all recommended services, or a date prior to completing
CR program due to specific reasons. This date should closely correspond to the
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution
patient’s last documented rehabilitation visit. Note: it must not be the date of a
post-CR program follow-up.
Data Source: Patient’s chart.
Unknown: Not documented
Discharge Summary Sent To Primary Care Physician
Was CR discharge summary sent to patient’s primary care provider?
Data Source: Patient’s chart
Data Entry:
 Yes
 No
 Unknown: Not documented
Discharge Summary Elements
If there was a discharge summary generated, did it include the following 4 elements?
1. a description of the patient’s lifestyle risk factors (physical activity, diet and smoking
as relevant),
2. medical risk factors (blood pressure, lipids and glucose as relevant),
3. cardiac medications, and
4. and long-term management goals.
Data Source: Patient’s chart
Data Entry:
o Yes – all 4 were fully included
o Partial – some but not all of these elements were included in the discharge
summary
o No
o Not applicable – there is no discharge summary for this patient
o Unknown: Not documented
Discharge Summary to Patient
Was the patient provided with a lay summary of their progress and updated exercise
prescription at program exit?
Data Source: Patient’s chart
Data Entry:
 Yes
 No
 Unknown: Not documented
RISK FACTORS AT INTAKE
Physical Activity History
13
Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Does the patient report that they accumulated at least 150 minutes of moderate- to
vigorous-intensity aerobic physical activity per week, in bouts of
10 minutes or more? (CSEP / QI consistent)
Data Sources: Initial intake visit, patient interview/questionnaire. Patient asked to
describe their physical activity history.
Data Entry:
 Yes – The patient reports that they participate in moderate to vigorousintensity physical activity for 150 minutes per week.
 Partial – The patient reports that they engage in some physical
activity, but not 150 mins per week
 No - The patient reports that they are not physically active
 Unknown: Not documented e.g., the patient’s physical activity
cannot be determined by the sources defined or the reliability of the
information is questionable.
Hyperlipidemia
Patient has a documented history of dyslipidemia diagnosed and/or treated by a
physician.
Data Source: History & Physical, Emergency Department record/notes, Nursing
Admission notes, Physician’s progress notes, lab results
Data Entry:
 Yes - if there is a history of Hyperlipidemia documented, if patient is
on lipid-lowering medications prescribed to treat dyslipidemia and/or
if LDL >2.0 mmol/L in patients with vascular disease, including CAD,
or diabetes
 No - if there is no documented history of or treatment for
Hyperlipidemia
 Unknown: Not documented or if there is no mention of
Hyperlipidemia in any of the recommended sources listed above.
Hypertension
Patient has a documented history of hypertension diagnosed and/or treated by
a healthcare provider. Treatment may include medication, diet and / or
exercise. Any of the following terms apply:
 Accelerated Blood Pressure
 Benign hypertension
 Elevated blood pressure (BP)
 High blood pressure (BP)
 Hypertension (HTN)
 Hypertensive heart disease
 Labile hypertension
 Renal hypertension
 Renovascular hypertension
 Systemic hypertension
 Systolic hypertension
 Uncontrolled hypertension
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Those conditions that should NOT be considered hypertension are:
 Intraocular hypertension
 Portal hypertension
 Pulmonary hypertension (any)
Data Source: History & Physical, Emergency Department record/notes, Nursing
Admission notes, Physician’s progress notes, current treatment for hypertension.
Data Entry:
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

Yes - if there is a history of Hypertension (values 140/90 mmHg for
patients without diabetes or 130/85 mmHg for patients with diabetes),
or patient is on blood pressure-lowering medication prescribed
specifically for hypertension
No - if there is no history of Hypertension or if there is no mention of
Hypertension in any of the recommended sources listed above;
Unknown: Not documented
Family History of CAD
Patient has/had any direct blood relative (parents, siblings, and children) who have been
diagnosed with angina, MI, PCI, CABG or sudden cardiac death for male relatives before
age 55 years or for female relatives before age 65 years.
Data Source: History & Physical, Emergency Department record/notes, Nursing
Admission notes, Physician’s progress notes, patient intake assessment.
Data Entry:
 Yes
 No
 Unknown: Not documented / unknown
Diabetes
Was there a documented diagnosis of diabetes or treatment for diabetes?
Any of the following documented terms apply:
 Adult Onset Diabetes Mellitus
 Diabetes
 Diabetes Mellitus (DM)
 Diet controlled diabetes
 DM Type I (1) or Type II (2)
 Drug induced diabetes
 Juvenile Diabetes
 Non-insulin dependent Diabetes Mellitus
 Any treatment/medication for diabetes
Those conditions that should NOT be considered as diabetes are:
 Diabetes insipidus
 History of gestational diabetes
 Impaired fasting glucose
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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
Glucose intolerance
Data Source: History & Physical, Emergency Department record/notes, Nursing
Admission notes, Physician’s progress notes, Intake Assessment, current treatment
for diabetes.
Data Entry:
 Yes - if diabetes is mentioned in any of the recommended sources listed
above or if the patient is on a medication used to treat diabetes.
 No - if there is no history of diabetes or if there is no mention of diabetes
in any of the recommended sources listed above.
 Unknown: ‘Not documented’
Diabetes Type
If “Yes” is indicated above, enter:
 Type 1
 Type 2
 Unknown: Not documented
Sleep Apnea
Patient has a documented history of sleep apnea
Data Source: History & Physical, Emergency Department record/notes,
Nursing
Admission notes, Physician’s progress notes, Intake Assessment, current
treatment for diabetes.
Data Entry:
 Yes
 No
 Unknown: Not documented
.
DISEASE SEVERITY INDICATORS AT INTAKE
CCS Angina Class
Enter the corresponding Canadian Cardiovascular Society Angina Class at the
time of intake. The CCS Angina Class must be determined post –
referral event and should be assessed at the time of intake. If not
assessed at
intake and no post-event documentation is available, select Unknown from the
pick list.
Data Source: Face sheet of the patient chart, Admission history, History and
Physical, Nursing Admission note, Physician’s progress notes, hospital
information system, Discharge summary or angiography or echocardiography
test reports.
Data Entry: Choices available are:
 0 – Asymptomatic
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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1 - Ordinary physical activity such as walking or climbing does not
cause angina. Angina with strenuous, rapid or prolonged exertion
at work or recreation.
2 - Slight limitation of ordinary activity. Walking or climbing
stairs rapidly, walking uphill, walking or climbing stairs after
meals or in cold or in wind, or under emotional stress or during the
few hours after wakening. Walking more than 2 blocks on the level
and climbing more than one flight of stairs at a normal pace and in
normal conditions.
3 - Marked limitation of ordinary physical activity. Walking one or
two blocks on the level or climbing one flight of stairs in normal
conditions and at a normal pace.
4 - Inability to carry out any physical activity without discomfort;
angina may be present at rest
Unknown: Not documented
NYHA class
Enter a value from I to IV as indicated at intake. The NYHA Functional Class
needs to be determined post-referral event and should be assessed at the time
of intake. If not assessed at intake and no post-event documentation is
available, select Unknown from the pick list.
Data Source: Face sheet of the patient chart, Admission history, History and
Physical, Nursing Admission note, Physician’s progress notes, hospital
information system, Discharge summary or angiography or echocardiography
test reports.
Data Entry: Choices available are:
 I - Patients with cardiac disease but without resulting limitations
of physical activity. Ordinary physical activity does not cause
undue fatigue, palpitation, dyspnea, or anginal pain
 II - Patients with cardiac disease that results in a slight limitation
of physical activity. Patients are comfortable at rest, but ordinary
physical activity results in fatigue, palpitation, dyspnea, or anginal
pain
 III - Patients with cardiac disease that results in a marked
limitation of physical activity. Patients are comfortable at rest, but
less than ordinary physical activity results in fatigue, palpitation,
dyspnea, or anginal pain
 IV - Patients with cardiac disease that results in an inability to
carry on any physical activity without discomfort; fatigue,
dyspnea, or anginal pain may be present; if any physical activity is
undertaken, symptoms increase. Symptoms may be present at rest.
 Unknown: Not documented
LV Function or LV Function Exact – if one is chosen, the other should grey out.
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Enter the exact left ventricular ejection fraction (LVEF), if available.
OR
If exact LVEF unavailable, enter the appropriate value from the pick list
provided to indicate the patients LVEF or degree of left ventricular function.
LV Function to be assessed post-referral event and/or within 6 months of
Intake. If there is no available documentation, select Unknown from the pick
list.
Data Source: Physician notes: Admission history, History and Physical,
Admission note, Physician’s progress notes, Discharge summary, or referral
note; Primary source documentation: angiography or echocardiography test
reports.
Data Entry: Select only one of the following that corresponds to the patients
level of left ventricular function.
 Normal ≥50% or greater CCS = Normal >50%
 Mild 40% and 49% CCS = Slightly reduced (41-50%)
 Moderate 30% and 39% CCS = Moderately reduced (31-40%)
 Severe <30% CCS = Severely reduced (≤30%)
 LV Function not assessed (CCS definition)
 Unknown: Not documented.
PROGRAM COMPONENTS DELIVERED
Information regarding the service referral data elements can most likely be found in the
patient chart. This could be offered internal or external to the CR program.
Exercise Sessions Prescribed
Enter the total number of exercise classes scheduled for the patient’s cardiac rehab
program.
Unknown: ‘Not documented’
Exercise Sessions Completed
Enter the total number of exercise classes attended by the patient during their rehab
program.
Unknown: ‘Not documented’
Education
Was the patient offered group or individual education within the program, particularly
that counselled patients regarding self-management for heart-healthy behavior
changes?
 Offered and Accepted
 Offered and Declined - If a patient does not accept or declines the offer
 Not Offered
 Unknown: Not documented
Nutrition counselling
Was the patient offered group or individual nutrition counselling?
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Offered and Accepted
Offered and Declined - If a patient does not accept or declines the offer
Not Offered
Unknown: Not documented
Smoking Cessation Counselling or Treatment
Was the patient offered smoking cessation counselling or treatment?
 Offered and Accepted
 Offered and Declined - If a patient does not accept or decline the offer please
 Not Offered
 Not applicable - If patient is a non-smoker
 Unknown: Not documented
Stress Management
Was the patient offered a stress management class or program?
 Offered and Accepted
 Offered and Declined
 Not Offered
 Not applicable
 Unknown: Not documented
Depression Counselling or Treatment
Was the patient offered a depression counselling program or other treatment (e.g.,
anti-depressants)?
Data Entry: Choices available are:
 Offered and Accepted
 Offered and Declined - If a patient does not accept or declines the offer
 Not Offered
 not applicable – patient is not depressed
 Unknown: Not documented
Promotion of Post-CR Physical Activity
Was patient provided an exit exercise prescription and an intervention to promote
long-term physical activity post-CR (e.g., motivational interviewing?)
Data Entry: Choices available are:
 Yes
 No
 Unknown: Not documented
INTAKE & DISCHARGE MEASUREMENTS
The following measures are to be completed at program intake and discharge. If the patient
is scheduled to have labs done as part of his/her admission and/or discharge evaluation, you
can use those results in the corresponding sections.
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Use the values from the most recent test date you can find in the medical record that is no
earlier than one (1) year prior to the assessment date. Do not use values that are more than
one year old at the time of the assessment.
For example, if the patient’s enrollment date is in November and he/she had lipid results
from three months earlier (in August), use these values. If there are no entry values within the
one-year time limit, enter “unknown”. If the patient’s discharge was subsequently in January
but he/she did not have any repeat lipid tests done, DO NOT repeat the previous values.
Instead, enter “unknown”.
BIOCHEMISTRY
Note: Blood work must be done under standard fasting conditions (9- 12 hours since last
meal; Canadian Lipid Guidelines, 2006).
Blood Sugar Profile
FBS (mmol/L)
This refers to the patient’s fasting blood glucose level.
Data Source: (1) Lab Report, (2) Emergency Department record/notes, (3)
History & Physical, (4) Progress note.
Data Entry:
Enter in the space provided the value obtained for fasting glucose.
Add other options in a dropdown format:
- Not documented /unknown
HBA1c (percent)
This refers to the patient’s glycosylated hemoglobin level.
Data Source: (1) Lab Report, (2) Emergency Department record/notes, (3)
History & Physical, (4) Progress note.
Data Entry:
Enter in the space provided the value obtained for glycosylated hemoglobin.
This value should be entered as a decimal. For example, an HbA1c of 6%
should be entered as 0.06.
Add other options in a dropdown format:
 Not documented /unknown
Lipid Profile (mmol/L)
Total Cholesterol (TC) (mmol/L)
What was the patient’s total cholesterol value.
Data Source: (1) Lab Report, (2) Emergency Department record/notes, (3)
History & Physical, (4) Progress note.
Data Entry: Enter the value for total cholesterol in mmol/L
Add other options in a dropdown format:
- Not documented / unknown
Triglycerides (TG) (mmol/L)
What was the serum triglycerides (TG) result?
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Data Source: (1) Lab Report, (2) Progress note.
Data Entry: Enter value obtained for serum Triglycerides in mmol/L.
Add other options in a dropdown format:
Not documented / unknown
High Density Lipoprotein (HDLC) (mmol/L)
What was the HDL cholesterol result?
Data Source: (1) Lab Report, (2) Progress note.
Data Entry: Enter value obtained for HDL cholesterol (HDL) in mmol/L.
Add other options in a dropdown format:
- Not documented / unknown
Low Density Lipoprotein (LDLC) (mmol/L)
What was the LDL cholesterol result? (may be called non-HDL)
Data Source: (1) Lab Report, (2) Progress note.
Data Entry: Enter value obtained for LDL cholesterol (LDL) in mmol/L.
Add other options in a dropdown format:
- Unknown (If there are no entry values within the one-year time limit; or, the
patient did not have any repeat lipid tests done at discharge)
- Not documented / unknown
ANTHROPOMETRIC
Weight (KG)
Weigh the patient prior to exercise without shoes, pockets emptied, and while
wearing his/her typical or usual exercise clothes. Record weight to the nearest tenth of
a kilogram if using a digital scale, to the nearest quarter pound if using a balance
beam scale. The scale should be placed on a solid, level surface.
Data Source: Direct measurement at the intake assessment.
Data entry: Enter the patient’s weight to the nearest 10th of a kilogram (i.e.
78.0 kg).
Add other options in a dropdown format:
- Not documented (unknown)
Height (cm)
Measure the patient’s height in stocking feet to the nearest whole centimetre. Have
the patient stand erect with the heels, buttocks, back of shoulders, and back of head
against the vertical scale. With the patient holding their breath, bring the horizontal
bar into contact with the highest point on the head.
Data Source: Direct measurement at the intake and discharge assessment visit.
Data Entry: Enter the patient’s height to the nearest cm. The number you
enter will be three digits (e.g. 172).
Add other options in a dropdown format:
- Unknown: Not documented
Waist (cm)
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Enter the patient’s waist measurement in centimetres (cm), at the approximate
midpoint between lower margin of the last palpable rib and top of the iliac crest
(WHO). Patient should stand with arms at sides, feet positioned close together, with
weight evenly distributed across feet. Assess at end of normal expiration when lungs
are at functional residual capacity. Take without clothing – directly over skin; if not
possible, over light clothing.
Data Source: Direct measurement at the intake and discharge assessment.
Data entry: Enter value obtained from patient’s waist measurement to the
nearest centimetre.
Add other options in a dropdown format:
- Not documented (unknown)
HEMODYNAMIC
2009 Canadian Hypertension Education Program (CHEP) Recommended Technique for
Measuring Blood Pressure
Place the cuff so that the lower edge is 3 cm above the elbow crease and the bladder is centered over the brachial
artery. The patient should be resting comfortably for 5 minutes in the seated position with back support.
The arm should be bare and supported with the antecubital fossa at heart level, as a lower position will result in
an erroneously higher SBP and DBP. There should be no talking, and patients’ legs should not be crossed.
At least three measurements should be taken in the same arm with the patient in the same position. The
first reading should be discarded and the latter two averaged.
2014 Updated CHEP Recommendations for accurate measurement of blood pressure:
https://www.hypertension.ca/en/professional/chep/diagnosis-measurement/accuratemeasurement-of-blood-pressure
Systolic Blood Pressure / Diastolic Blood Pressure (SBP / DBP) (mm)
Enter the patient’s systolic blood pressure (mmHg) and the patient’s diastolic
blood pressure (mmHg). BP assessement should be undertaken
manually or with a validated automated device only (e.g., see:
http://www.dableducational.org/).
Data Source: Direct measurement at the intake assessment.
Data entry: Enter value obtained from patient’s SBP and DBP.
Add other options in a dropdown format:
 Not documented /unknown
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Pulse Rate (bpm)
Enter the patient’s heart rate (bpm).
Data Source: Direct measurement at the intake assessment.
Data entry: Enter value obtained from patient’s pulse measurement.
Add other options in a dropdown format:
 Not documented / unknown
FUNCTIONAL CAPACITY TESTS
The following measures are required at program intake and discharge.
NOTE
An exercise stress test on a treadmill using a standardized protocol such as the Ramp,
Bruce or Modified Bruce is recommended. A previously-completed symptomlimited maximal stress test can be entered, providing it was completed postreferral event and within 1 month of the intake date. Alternatively a cycle test
can be performed (see below for calculation to convert watts to METs).
Some programs do not perform routine stress tests. In this instance, another functional
capacity test such as a 6 minute walk test should be reported.
Type of Functional Capacity Assessment
Was an assessment of functional capacity performed?
Data Entry: Check all that apply:
 GXT
 6 minute walk test
 Duke Activity Status Index
 Other
 None
 Not applicable
 Not documented
Patient Cleared for Stress Testing
Did the patient meet the ACSM safety recommendations for undertaking a stress test. For
example, patients who cannot walk on a treadmill unaided, or who cannot cycle on a bike
ergometer.
 Yes
 No
 N/A - this program does not do stress testing (see below for other
functional tests)
 Unknown: Not documented
Functional Test Date
When was the functional test performed?
Data Entry: Please use the calendar to enter the date of the exercise stress test.
Add other options in a dropdown format:
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Not applicable
Unknown: Not documented
GXT Protocol
What was the GXT protocol used for the exercise stress test?
Data Source: Exercise stress test report.
Data Entry: Choices available are:
 Bruce
 Bruce-Modified
 Ramp
 Other
 Not applicable
 Unknown: Not documented
GXT Modality
Data Source: Exercise stress test report.
Data Entry: Choice available are:
 Treadmill
 Cycle
 Other
 Not applicable
 Not documented /Unknown
Exercise Capacity Directly Measured
Indicate if exercise capacity level was directly measured using gas analysis.
Data Source: Exercise stress test report.
Data Entry:
 Yes - if exercise capacity was directly measured by oxygen uptake
(CPA test)
 No - if exercise capacity was estimated using standard equations
from final workload level completed.
 Not applicable
 Unknown: Not documented
Resting SBP (mm)
What was the patient's resting systolic blood pressure immediately before the functional
stress test?
Data Source: Exercise stress or other functional test reports.
Data Entry:
 If two BPs were recorded for the same time or it was taken in both
arms enter the highest systolic reading.
 If a range is given, record the mid-value i.e. 120-130 record 125.
 not applicable (e.g., patient has a VAD)
 Not documented / unknown
Resting DBP (mm)
What was the patient's resting diastolic blood pressure immediately before the functional
test?
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Data Source: Exercise stress test report.
Data Entry:
 If two BPs were recorded for the same time and have the same
diastolic BP record the one with the highest diastolic value.
 If a range is given, record the mid-value i.e. 60 – 70 record 65.
 If the first diastolic BP is recorded in the chart as “p” for palpatation
find the next BP with both systolic and diastolic values recorded
numerically.
 Not documented / unknown
Peak SBP (mm)
What was the patient's peak systolic blood pressure during the funtional test?
Data Source: Exercise stress test reports.
Data Entry:
 If two BPs were recorded for the same time or it was taken in both
arms enter the highest systolic reading.
 If a range is given, record the mid-value i.e. 120-130 record 125
 not applicable (e.g., patient has a VAD)
 Not documented / unknown
Peak DBP (mm)
What was the patient's peak diastolic blood pressure during the functional test?
Data Source: Exercise stress test or other functional test report.
Data Entry:
 If two BPs were recorded for the same time and have the same
diastolic BP record the one with the highest diastolic value.
 If a range is given, record the mid-value i.e. 60 – 70 record 65.
 If the first diastolic BP is recorded in the chart as “p” for palpatation
find the next BP with both systolic and diastolic values recorded
numerically.
 Not documented / unknown
Resting Heart Rate (HR)
What was the patient’s resting heart rate immediately prior to the start of the functional
test?
Data Source: Exercise stress test or other functional test report.
Data Entry:
 Enter the resting heart rate (beats per minute) recorded on the
electrocardiogram during the exercise test. In the event that the HR is
not accurate on the cardiogram, a palpated HR (apical or radial) may
be used.
 Not documented / unknown
Peak Heart Rate (HR)
What was the patient’s peak heart rate during the exercise stress test?
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Data Source: Exercise stress test or other functional test report.
Data Entry:
 Enter the peak heart rate (beats per minute) recorded on the
electrocardiogram during the exercise test. In the event that the HR is
not accurate on the cardiogram, a palpated HR (apical or radial) may
be used.
 Not documented / unknown
Exercise Time
What was the duration of exercise during the funtional stress?
Data Source: Exercise stress test or other functional test report.
Data Entry: Enter the duration of exercise in minutes. For example, a duration
of 14 minutes and 30 seconds would be entered as 14.5.
 Add other options in a dropdown format:
 Not applicable
 Not documented / unknown
6 min walk distance (m)
Report the distance attained during the 6-minute walk test in feet or meters. (Please refer
to “ATS Statement: Guidelines for the Six-Minute Walk Test” [Am J Respir Crit Care
Med. 2002; 166: 111-117. doi: 10.1164/rccm.166/1/111]
Data Entry:
o Enter meters walked
o Not applicable
o Not documented / unknown
Symptom-Limited
Was the functional test stopped early due to patient symptoms?
Data Source: Exercise stress or other functional test report.
Data Entry:
 Yes
 No
 Not applicable
 Not documented / unknown
Reason for Premature Termination
If the exercise stress or other functional test was terminated, provide the reason why.
Data Source: Exercise stress test or other functional test report.
Data Entry: Choices available are:
 Fatigue/leg pain
 Dyspnea
 Angina
 ST changes
 Arrhythmias
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Drop in BP
Hypertensive response
Presyncopal
Patient request
Equipment problems
MD instruction
Other
Not applicable – no premature termination
Not documented / unknown
Angina
Indicate if patient had documented angina during the exercise stress or other functional
test.
Data Source: Exercise stress test report and or exercise test ECG or other
functional test report
Data Entry: Choices available are:
 None
 Non-limiting
 Stopped Test
 Not documented / unknown
Borg 10 Scale
If the Borg 10 Scale was used, enter the maximum Borg rating achieved at completion of the
exercise stress or other functional test. The Borg rating is used to assess perceived level of
exertion.
Data Source: Exercise stress test or other functional test report.
Data Entry:
 Value from 0-10
 Add other options in a dropdown format:
 Not applicable – did not use the Borg 10 scale
 Not documented / unknown
0
0.5
1
2
3
4
5
6
7
8
9
10
10-Grade Scale
Nothing
Very, very weak
Very weak
Weak (light)
Moderate
Somewhat strong
Strong (heavy)
Very strong
Very, very strong
Borg 15 Scale
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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If the Borg 15 Scale was used, enter the maximum Borg rating achieved at completion of the
exercise stress or other functional test. The Borg rating is used to assess perceived level of
exertion.
Data Source: Exercise stress test or other functional test report.
Data Entry:
 Value from 6-20
 Add other options in a dropdown format:
 Not applicable – did not use the Borg 15 scale
 Not documented / unknown
15-Grade scale
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Very, very light
Very light
Fairly light
Somewhat hard
Hard
Very hard
Very, very hard
Max ST Depression
Indicate the maximum level of ST segment depression. ST depression is defined as
horizontal or down-sloping ST depression measured at 60 or 80ms after the J point.
Data Source: Physician interpretation on the exercise stress test report
and/or exercise test ECG.
Data Entry: Write in number of millimeters noted on the test.
 Add other options in a dropdown format:
o Not applicable – no exercise ECG performed
o Not documented / unknown
Peak METs
Indicate the peak METs achieved during the test or assessment in the space provided. The
METs can be estimated from standard equations using speed and grade, or can be
calculated from the direct measurement of oxygen consumption using gas analysis.
To calculate METs from watts see:
http://sportsartamerica.com/SAF/support/technicalsupport/techtips/General%20Info/Watt
s_to_METs_Conversions.pdf
Data Source: Exercise stress test or other functional assessment.
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Data Entry: Enter the numeric value of the peak METs as indicated by the
exercise stress test report to the nearest 1/10 of a MET (i.e. 5.4 METs).
 other options in a dropdown format:
o Not applicable – METS not assessed
o Not documented / unknown
Risk assessment
Was a risk assessment for adverse cardiovascular assessment performed?
Data Source: CR chart
Data Entry: Check all that apply:
 Duke treadmill score
 Cardiometabolic fitness risk stratification
 Framingham risk score
 Other
 No
 Not documented / unknown
Duke Treadmill Score
The DTS is a weighted index combining treadmill time, ST segment deviation
(depression or elevation), and exercise-induced angina. It provides accurate diagnostic
and prognostic information.
DTS = Exercise Time (regular Bruce protocol minutes)* – (5x ST deviation) – (4x
Angina index)
Can be “back-calculated” from non-Bruce protocols solving for METs.
Angina Index: 0=none, 1=during test, and 2=angina stopped test.
Distinction between exercise-induced angina and non-anginal chest pain is based on the
clinical judgement of the physician supervising the stress test. Emphasis is placed on
reproducing the patient’s usual presenting symptoms and the classic features of typical
angina.
Data Source: Exercise stress test report
Data Entry: Enter value between –25 (highest risk) and +15 (lowest risk)
 Add other options in a dropdown format:
o Not applicable as appropriate assessments were not performed to
compute DTS
o Not documented / unknown
*
OTHER ASSESSMENTS: SELF-REPORTED HEALTH BEHAVIOURS &
RETURN TO WORK
The following measures are recommended at program intake and discharge.
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Physical Activity -Total
Canadian Physical Activity Guidelines recommend that individuals accumulate at least
150 minutes per week of moderate-to vigorous-intensity physical activity, performed in
10 minute bouts or longer. Based on the last 7 day period, how many minutes does the
patient report they accumulated of moderate-to vigorous-intensity aerobic physical
activity per week (i.e., at least brisk walking), in bouts of 10 minutes or more?
Data Sources: Initial intake and discharge visit, patient interview/questionnaire. Patient
asked to describe their physical activity level.
Data Entry:
 enter number of minutes
 Unknown: Not documented
Physical Activity -Frequency
Based on the last 7 day period, how many days does the patient report they engaged in
moderate-to vigorous-intensity aerobic physical activity (i.e., at least brisk walking)?
Data Sources: Initial intake and discharge visit, patient interview/questionnaire. Patient
asked to describe their physical activity frequency.
Data Entry:
 enter number of days
 Unknown: Not documented
Resistance Training
Canadian Physical Activity Guidelines recommend that individuals perform resistance
training using major muscle groups for at least two days per week to add muscle and
strength. Based on the last 7 day period, does the patient report that they perform
resistance training at least two days per week?
Data Sources: Initial intake and discharge visit, patient interview/questionnaire. Patient
asked to describe their strength training routine.
Data Entry:
 Yes – The patient reports that they perform resistance training at least two
days per week.
 Partial – The patient reports that they perform resistance training, but not two
days per week.
 No - The patient reports that they do not engage in strength training or the
patient’s strength training cannot be determined by the sources defined or the
reliability of the information is questionable.
 Unknown: Not documented
Smoking
Does the patient smoke at the present time (intake and discharge)? Note: pertains to
cigarette, cigar and pipe smoking
Data Entry: Choices available are (CCS):
 Never = no history of any form of tobacco,
 Current = use of any form of tobacco (cigarettes, cigar, pipe) within
one month of referral date,
 Former = use of any form of tobacco > one month of referral date,
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Unknown: Not documented
Dietary - % Kcal saturated fat
Use the results from a standardized, validated tool or assessment by a registered dietitian
for estimating the percentage of daily calories as saturated fats (AACVPR).
Data Entry: Report value to the nearest whole number.
Add other options in a dropdown format:
 Unknown: Not documented
Daily fruit/vegetable servings
Self-reported daily fruit and vegetable servings / day. Report value to the nearest whole
number (AACVPR).
Data Entry: Report value to the nearest whole number.
Add other options in a dropdown format:
 Unknown: Not documented
Employment Status
Select the most appropriate response to describe the patient’s employment status at the
time of intake to and discharge from cardiac rehabilitation. Note:
Participation in the labour market takes precedence e.g. code as ‘part-time’
if an individual is both a student and is employed part-time. (CCS)
Data Source: Admission history, History and Physical, Consultant’s notes, Nursing
Admission note, Intake Assessment.
Data Entry: Available choices are:
 Employed full-time, that is 35 or more hours per week
 Employed part-time, that is, less than 35 hours per week
 Self-employed (primary occupation)
 Unemployed, but looking for work
 Student
 Retired
 Not in the paid workforce (homemaker, unemployed, not looking for
work)
 On disability
 Other
 Unknown: Not documented
Desired Occupation Status Achieved
Was the patient’s desired occupational status achieved by discharge from cardiac
rehabilitation?
Data Source: Discharge assessment/interview, patient’s chart.
Data Entry: Indicate:
 Yes - patient achieved his/her desired occupation status by discharge
 No - patient did not achieve his/her desired occupation status by discharge
 Not applicable
 Unknown: Not documented
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Work Return Date
Date that patient returned to work, if applicable.
Data Entry: Write in date:
Add other options in a dropdown format:
- Not applicable – patient retired or on long-term disability
- Unknown: ‘Not documented’
PSYCHO-SOCIAL INDICATORS
The following measures are recommended at program intake and discharge.
DEPRESSION
Because the HADS-D costs money to administer and the BDI-II is used more as a research tool,
in this iteration of the data dictionary we are recommending administration of the PHQ-2. It is
recommended as a screener by AHA (Lichtman et al., Circulation 2008), and also as an option
for screening in the CCS CR Quality Indicators.
PHQ-2:
Ask the patient: over the past 2 weeks, how often have you been bothered by any of the
following problems?
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
Response options are: not at all (0), several days (1), more than half the days (2), nearly every
day (3).
Measure Performed
Was a depression measure administered?
Data Entry: Choices available are:
 Yes
 No
 Unknown: Not documented
Measure
What tool was used to measure depression?
Data Entry: Choices available are:
 Hospital Anxiety & Depression Scale Depression Score (HADS-D)
 Beck Depression Inventory (BDI-II)
 PHQ-2
 Other
 Unknown: Not documented
Measure Score
What was the score of the depression measure?
If the PHQ-2 was used, please add up the number corresponding to the patient
response to questions 1 and 2.
Data Entry: Enter the numerical value.
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
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Add other options in a dropdown format:
o Unknown: Not documented
At or above cutoff
Was this score at or above the cutoff for depression?
For the PHQ-2, the cut-off is 3.
Data Entry: Choices available are:
 Yes
 No
 Unknown: Not documented
QUALITY OF LIFE
We suggest administering the 1-item Ladder of Life (Cantril H. The pattern of human
concerns. New Brunswick: Rutgers University Press, 1965.; see also Jaarsma et al.,
Measuring quality of life in heart failure: one versus multiple items. Neth Heart J: 2005;
13:338-42).
Measure Performed
Was a QOL measure administered?
Data Entry: Choices available are:
 Yes – Ladder of Life
 Yes – SF-12
 Yes - other
 No
 Not documented / unknown
SF-12 Score
What was the score of the SF-12 measure?
Data Entry: Enter the numerical value.
Add other options in a dropdown format:
o Not documented / unknown
Ladder of Life
Here is a picture of a ladder. The top of the ladder represents the best possible life
and the bottom the worst for you. Where on the ladder do you feel you personally
stand at the present time?
10 BEST POSSIBLE LIFE
9
8
7
6
5
4
3
2
1
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Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution
0 WORST POSSIBLE LIFE
Data Entry: Enter the numerical value from 0 - 10.
o Unknown: Not documented
MEDICATIONS
Enter all prescribed medications at intake and discharge from the CR program. Intake
medications could be those documented at the intake assessment or intake functional testing.
Discharge medications could be those documented at the time of the exit Functional Test or
during the Exit Assessment. Be sure to include any diabetic or anti-depressant agents.
Contraindicated Medications
Does this patient have any contra-indications to cardiac medications?
Data Entry: Choices available are:
 Yes
 No
 Unknown
 Not documented/ unknown
Contraindication class
If patient has a contraindication, to which class of drug?
Data Entry: Choices available are:
 Statin
 Beta-blocker
 Aspirin
 Other
 Not applicable
 Not documented / unknown
Medication Class
Indicate the therapeutic class of the medication(s).
Data Entry: All of the following classes should be reported, where prescribed:
angiotensin converting enzyme inhibitors, angiotensin II inhibitors, ARBs, centrallyacting antiadrenergic agents, peripherally-acting antiadrenergic agents, antianginal
agents, antiarrhythmic agents, anticoagulants, antihypertensive combinations, bile acid
sequestrants, calcium channel blocking agents, cardioselective beta-blockers, fibric acid
derivatives, HMG-CoA reductase inhibitors, inotropic agents, loop diuretics,
miscellaneous antihyperlipidemic agents, non-cardioselective beta blockers, platelet
aggregation inhibitors, potassium-sparing diuretics, salicylates, sulfonylureas, thiazide
diuretics, thiazolidinediones, vasodilators. Diabetes drugs should also be reported:
metformin, DPP4’s, LLP-1s, insulins.
34
Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution
Name
Choose the generic and brand name of all cardiovascular-realted medications the patient
is prescribed at intake and discharge.
Data Entry: Please see Appendix A for the list of medications and therapeutic classes.
- Include option for unknown / Not documented
Dose, units
 Indicate the doses of all noted medications.
Data Entry: Enter numeric value.
 Indicate the medication unit(s) of the dose(s).
Data Entry: Choices available are:
 mg
 ug
 g
 U
 mL
 mg/hr
 packet
 mg/day
 ug/day
 Not documented / unknown
Frequency
 Indicate the frequency that the patient was prescribed to take the medication(s).
Data Entry: Enter the number of times per day that patient was prescribed to take the
medication(s).
 Indicate the medication schedule (frequency and/or time of day).
Data Entry: Choices available are:
 od
 qam
 ac breakfast
 ac lunch
 qpm
 ac dinner
 qhs
 bid
 tid
 qid
 tid on a qid schedule
 on in am, off at bedtime
 q 5min x 3 prn
 od prn
 as needed (max 20 pieces/day)
 as needed (max 80 sprays/day)
 as needed (6-16 cartridges/day)
35
Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution


q4h prn
Not documented / unknown
NOTE: By clicking “»” next to each medication on the Medication home screen, the exact same
information will populate the Discharge medication list. This is useful for medications and
dosages that do not change from intake to discharge from the CR program.
Vitamins
Is the patient taking any vitamins?
Data Entry: Choices available are:
 Yes
 No
 Unknown/not documented
Herbal / complementary or alternative pills
Is the patient taking any herbal or unprescribed non-evidence-based therapies?
Data Entry: Choices available are:
 Yes
 No
 Unknown/not documented
36
Copyright © Canadian Association of Cardiovascular Prevention and Rehabilitation 2014
To be used with permission only. Not for re-distribution