PATIENT HOME DAILY RECORD – HEARTWARE® VENTRICULAR ASSIST SYSTEM
Patient Name: ________________________________________________________
Date of Implant: _______________________________
Patient/Pump Data
Date
Time
Weight
Temperature
Blood pressure
Pump flow (LPM)
Pump speed (RPM)
Pump power (Watts)
Exit Site Dressing change
Exit Site
□clean/dry
□drainage
□swelling
□pain
□inflamed/red
□clean/dry
□drainage
□swelling
□pain
□inflamed/red
□clean/dry
□drainage
□swelling
□pain
□inflamed/red
□clean/dry
□drainage
□swelling
□pain
□inflamed/red
□clean/dry
□drainage
□swelling
□pain
□inflamed/red
□clean/dry
□drainage
□swelling
□pain
□inflamed/red
□clean/dry
□drainage
□swelling
□pain
□inflamed/red
Symptoms
Alarms
Blood Thinning Medications
Aspirin
Coumadin
INR
For any emergency (for example, pump stop, loss of power to the pump, broken wires, damage to the pump motor or system controller, and/or change in
health affecting the heart, etc), please call ______________________________________________________________