Discharge Summary for Acute Coronary Syndromes Management
To be sent to relevant doctors (e.g. general practitioner, regular cardiologist/general physician etc) and a copy can be given to the patient/carer.
General Practitioner Cardiologist/
General physician
Admission date: ____ / ____ / ______Discharge date: ____ / ____ / ______
Principal discharge diagnosis □ STEMI □ NSTEMI □ Unstable angina pectoris
□ Other …………………………………………………………………………………………….
Secondary discharge diagnoses………………………………………………………………………………………………………………….
Brief history of admission (including inpatient investigations, procedures)
______
Identified risk factors/lifestyle modifications requiring follow up
□ Diabetes ______□ Blood pressure/renal______
□ Smoking ______□ Lipids ______
□ Weight ______□ Alcohol______
□ Physical activity ______□ Depression______
□ Cardiac rehabilitation ______
Information provided to patient/carer
Educational literature provided, explained to patient/carer, understanding verbalised□ Yes □ No
Cardiac risk factors discussed□ Yes □ No
Chest pain management discussed and written plan provided□ Yes □ No
Medications provided and explained to patient/carer□ Yes □ No
ACS discharge medicines
(include generic name of drug used and reason for contraindication if not prescribed)
MedicinePrescribeDose and FrequencyReason not ordered
Aspirin□Yes□No ......
Clopidogrel/prasugrel/ticagrelor□Yes□ No......
Betablocker□Yes□ No......
ACE Inhibitor/ARB*□Yes□No......
Statin□Yes□ No......
Sublingual glyceryl trinitrate PRN□Yes□ No......
* ACEInhibitor = Angiotensin converting enzyme inhibitor, ARB = Angiotensin receptor blocker
Other discharge medications (list)
______
Allergies/adverse drug reactions ……………………………………………………………………………………………………………..
This patient may benefit from a Home Medicines Review (HMR)□ Yes □ No
Discharge medication list forwarded to community pharmacy□ Yes □ No
Scripts completed□ Yes □ No
Other relevant details regarding ongoing ACS management plan
______
Required outpatient tests or procedures
Tests or procedures booked and dates ______
______
Follow up appointments/referrals
Cardiologist Date ..... / ..... / .....
Other specialist (specify)……………………………….. Date ..... / ..... / .....
Cardiac Rehab Location …………………………………….. Date ..... / ..... / .....
Assessment of cardiac riskfactors
(this section may be completed by ward or cardiac educator nurse)
Identified risk factors/lifestyle modifications requiring follow up
Diabetes / BP/Renal / Smoking / Lipids / Weight / Alcohol / Physical activity / Depression / Cardiac rehab1 □ / 2 □ / 3 □ / 4 □ / 5 □ / 6 □ / 7 □ / 8 □ / 9 □
1. Diabetes assessment
□ No diabetes□ Type 1□ Type 2
Seen by diabetic educator this admission□ Yes □ No
Treatment□ Not currently receiving
□ Diet and exercise only
□ Oral hypoglycaemics
□ Oral hypogycaemics & insulin
□ Insulin
Results
Random blood glucose level (BGL) ______mmol/L (If > 7.8 mmol/L,see fasting level & HbA1c)
Fasting blood glucose level ______mmol/L
□ Normal < 6.1 mmol/L □ Impaired 6.1-6.9 mmol/L□ Diabetic > 7.0 mmol/L
HbA1c ______% (HbA1c abnormal > 7%)
2. Blood pressure and renal function
Is the patient on medication for hypertension?□ Yes □ No
Does BP control achieve National Heart Foundation (NHF) guidelines?
Dipstick Proteinuria / Diabetes / Renal insufficiency / Age / Tick one goal / NHF BPNIL / No / No / >65 / □ / <140/90
NIL / No / No / <65 / □ / <130/85
+/- <0.25 g/d / Yes/No / Yes / Any / □ / <130/85
+/- <0.25 g/d / Yes / No / Any / □ / <130/85
++ 0.25 g/d / Yes/No / Yes/No / Any / □ / <130/85
+++ >1 g/d / Yes/No / Yes/No / Any / □ / <125/75
BP Goal achieved □ Yes □ No
3. Smoking
□ Never □ Quit < 1 year □ Quit > 1 year □ Current
If current, how many per day? ______If not a regular smoker, how many per week? ______
□ Refer to Quitline □ Provide Quitline brochures □ Provide pharmacotherapy
4. Lipid profile
Lipid results / NHF Goal / Goal achievedTotal chol ____ mmol/L / <4 mmol/L / □ Yes / □ No
LDL – C ____ mmol/L / <2 mmol/L / □ Yes / □ No
HDL – C ____ mmol/L / >1 mmol/L / □ Yes / □ No
Triglycerides ____ mmol/L / <1.5 mmol/L / □ Yes / □ No
5. Weight managementHeight ______cm Weight _____ kg BMI ____
□ BMI 18.5 – 24.9Normal / □ BMI 25 – 29.9
Overweight / □ BMI ≥ 30
Obese
NHF waist measurement goals are: Male <94 cm; Female <80 cm Waist measurement _____ cm
Nutrition: Seen by dietitician□ Yes □ No
6. Alcohol
□ Abstainer
□ Low risk (daily <2 drinks women, <4 drinks men)
□ Moderate risk (daily 3-4 drinks women, 5-6 men)
□ High risk (5 daily drinks women, 7 daily drinks men)
7. Physical activity
□ > 150 mins per weekSufficient / □ < 150 mins per week
Insufficient / □ No physical activity
Sedentary
8. Psychological
Patient demonstrated fears, anxieties and concerns about cardiac condition. GP requested to address these issues when reviewing patient. □ Yes □ No
9. Cardiac rehabilitation
‘Managing My Heart Health’ booklet given (or other similar publication)□ Yes □ No
NPS: Better choices, Better healthDMACS