Dr.
CARDIAC REHAB PHYSICIAN ORDERS
Name:
1.
BD:
Phone: 406-
Diagnosis:
Covered by Medicare:
NOT Covered by Medicare: (Please Indicate Diagnosis)
CABG
Cardiomyopathy
PTCA/Stent
Arrhythmias
MI
ASCHD
Stable Angina
Device: Pacemaker / ICD
Heart/Lung Transplant
Other: _________________
Valve surgery
Stable CHF: (LVEF 35% or less, NYHA class II to IV symptoms despite optimal heart
failure therapy for at least six weeks, had no recent (≤ 6 weeks) or planned (≤ 6 months)
major cardiovascular hospitalizations or procedures)
2.
Date of event:
/2014__
3.
Risk Classification:
(Indicate applicable condition)
Low Risk
-----------
Uncomplicated MI, CABG, PTCA, Atherectomy, Stents
Ejection fraction > 50%
No ischemic changes at rest or with exercise
No resting or exercise-induced complex arrhythmias
Functional Capacity > 6 ME
Moderate Risk
-------
Ejection fraction 31-49%
Abnormal response to exercise consistent with ischemia
Functional capacity < 6 METS
High Risk
-------------
Ejection fraction <30%
Complex ventricular arrhythmias at rest or with exercise
Survivor of sudden cardiac death
Complicated MI or Cardiac Surgery
Strongly positive stress test (> 2mm ST-segment depression)
Systolic BP falls or fails to rise with exercise
4.
Develop exercise prescription using Cardiac Rehab treatment plan, (copy available upon request).
One to three individualized exercise sessions a week up to 36 sessions or more as prescribed.
5.
Follow Cardiac Rehab policies & procedures consistent with KRMC emergency standing orders.
6.
Other Orders/Comments: _________________________________________________________
DATE:
Physicians signature:
PLEASE COMPLETE AND RETURN TO CARDIAC REHAB
3/2014
FAX: 751-4121
OFFICE: 751-4504