Individual Cardiac Treatment Plan rev 1/10 Name: DOB: Age: Date entered program: Diagnosis: Date of event: Allergies:

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1 Individual Cardiac Treatment Plan rev 1/10 Name: DOB: Age: Date entered program: Diagnosis: Date of event: Allergies: Risk strat for cardiac event: Physician: Office vs: low moderate high (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) PG #1 Exercise Date Exercise Date Exercise Date Exercise Date 6-MWT Stress test Other: 6-MWT Stress test Other: walked ft max HR walked ft max HR RPE SPO2 MET level RPE SPO2 MET level Exercise prescription Exercise prescription Exercise prescription Exercise prescription Mode TM B STP EG EL R Mode TM B STP EG EL R Mode TM B STP EG EL R Mode TM B STP EG EL R Frequency Frequency Frequency Frequency Duration Duration Duration Duration Intensity Intensity Intensity Intensity Progression Progression Progression Progression Angina with ex Y N THR Angina with ex Y N THR Angina with ex Y N THR Angina with ex Y N THR Resistance train Y N Wt# Reps Resistance train Y N Wt# Reps Resistance train Y N Wt# Reps Resistance train Y N Wt# Reps Hypertension Y N Medication Diet Hypertension Y N /Medication Diet Resting Peak Exercise BP Current BP: Current BP: Resting Peak Exercise HR Meds: Med change: Y N Med change: Y N Med change: Y N Home exercise: Home exercise: Home exercise: Home exercise: Type Frequency Type Frequency Type Frequency Type Frequency Duration Duration Duration Duration Resistance training: Y N Resistance training: Y N Resistance training: Y N Resistance training: Y N Self pulse RPE scale Self pulse RPE scale Self pulse RPE scale Education goals met: Y N Ex safety Equip orient Ex safety Equip orient Ex safety Equip orient S/S to report Wm-up/cl-dn S/S to report Wm-up/cl-dn S/S to report Wm-up/cl-dn Low Na diet Understand BP Low Na diet Understand BP Low Na diet Understand BP BP Medication Physical active BP Medication Physical active BP Medication Physical Active Individual exercise Rx (1) Individual exercise Rx (1) Individual exercise Rx (1) Individual exercise Rx (1) BP <140/90 or <130/80 if DM or CKD (1) BP <140/90 or <130/80 if DM or CKD (1) BP <140/90 or <130/80 if DM or CKD (1) BP <140/90 or <130/80 if DM or CKD (1) Aerobic active 30+min 5 days per week (1) Aerobic active 30+min 5 days per week (1) Aerobic active 30+min 5 days per week (1) Aerobic active 30+min 5 days per week (1)

2 (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) PG #2 Nutrition Date Nutrition Date Nutrition Date Nutrition Date Lipids: Total Chol HDL LDL Lipids: Total Chol HDL LDL Lipids: Total Chol HDL LDL Lipids: Total Chol HDL LDL Trig Trig Trig Trig Lipid med/supplement: Med change: Y N Med change: Y N Med change: Y N Diabetes: Y N FBS HbA1c Diabetes: NA FBS HbA1c Diabetes: NA FBS HbA1c Diabetes: NA FBS HbA1c Diabetes medication: Med change: Y N Random BS Med change: Y N Random BS Med change: Y N Random BS Monitor BS at home Y N freq BS in range Y N BS in range Y N BS in range Y N Weight management: WT HT Weight management: Weight management: Weight management: WT HT % fat Waist cir BMI Current WT Current WT % fat Waist cir BMI Wt goal: Wt goal: Wt goal: Wt goal: Special diet vitamins/supplements Alcohol daily weekly special none type amount Diet assess tool Diet assess tool score score Dietician consult: Y N Dietician consult: Y N Dietician consult: Y N Dietician consult: Y N Nurse/patient discussion Y N Nurse/patient discussion Y N Nurse/patient discussion Y N Nurse/patient discussion Y N Dietary goal: Dietary goal: Dietary goal: Dietary goal: Diet class Y N Diet class Y N Diet class Y N Diet class Y N Referral to Diabetes education Y N Referral to Diabetes education Y N Referral to lipid clinic Y N Referral to lipid clinic Y N Referral to wt management program Y N Referral to wt management program Y N S&S hypo/hyper glycemia S&S hypo/hyper glycemia S&S hypo/hyper glycemia Education goals met: Y N Relate Diabetes to CAD Relate Diabetes to CAD Relate Diabetes to CAD Eating Healthy Eating Healthy Eating Healthy LDL-C<100 if triglycerides are > 200 LDL-C<100 if triglycerides are > 200 LDL-C<100 if triglycerides are > 200 LDL-C<100 if triglycerides are > 200 non-hdl-c should be <130 (1) non-hdl-c should be <130 (1) non-hdl-c should be <130 (1) non-hdl-c should be <130 (1) LDL-C <70 for high risk patients (4) LDL-C <70 for high risk patients (4) LDL-C <70 for high risk patients (4) LDL-C <70 for high risk patients (4) HbA1c <7% (1) HbA1c <7% (1) HbA1c <7% (1) HbA1c <7% (1) BMI <25 Waist cir <40in M/<35in F (1) BMI <25 Waist cir <40in M/<35in F (1) BMI <25 Waist cir <40in M/<35in F (1) BMI <25 Waist cir <40in M/<35in F (1)

3 (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) PG #3 Education Date Education Date Education Date Education Date Learning Barriers: speech hearing vision literacy cognitive ready learn Knowledge test score: Knowledge test score: Family support Y N Family support Y N Family support Y N Family support Y N Tobacco use: Y N Tobacco use: Y N Tobacco use: Y N Tobacco use: Y N quit < 6 mo >6 mo Date started date quit Date quit Date quit Date quit Quit date set Quit date set Quit date set Quit date set # cigarettes smoked per day # cigarettes smoked per day # cigarettes smoked per day # cigarettes smoked per day Smokeless tobacco Y N amt Smokeless tobacco Y N amt Smokeless tobacco Y N amt Smokeless tobacco Y N amt Referral to Smoking cessation class Y N Referral to Smoking cessation class Y N Referral to Smoking cessation class Y N Referral to Smoking cessation class Y N Individual education and counseling Y N Individual education and counseling Y N Individual education and counseling Y N Individual education and counseling Y N Tobacco adjunct Y N Tobacco adjunct Y N Tobacco adjunct Y N Tobacco adjunct Y N Education class schedule given Y N Attended Ed classes Y N Attended Ed classes Y N Attended Ed classes Y N Tobacco triggers Tobacco triggers Tobacco triggers Education goals met: Y N CAD Cardiac A&P CAD Cardiac A&P CAD Cardiac A&P Risk factors Angina S/S Risk factors Angina S/S Risk factors Angina S/S Med compliance Sexuality Med compliance Sexuality Med compliance Sexuality Complete cessation of tobacco use (1) Complete cessation of tobacco use (1) Complete cessation of tobacco use (1) Complete cessation of tobacco use (1)

4 (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) PG #4 Psychosocial Date Date Date Date Psychosocial test: Psychosocial test: Tool used: Tool used: Score Score Psych Consult: Y N Psych Consult: Y N Psych Consult: Y N PsychConsult: Y N Physician referral Y N Physician referral Y N Physician referral Y N Physician referral Y N Psychotropic medication: Med change: Y N Med change: Y N Med change: Y N Stress management class: Y N Stress management class: Y N Stress management class: Y N Stress management class: Y N Uses stress management skills: Y N Uses stress management skills: Y N Uses stress management skills: Y N Uses stress management skills: Y N Education goals met: Y N Assess presence or absence of Assess presence or absence of Assess presence or absence of Assess presence or absence of depression using a valid screening tool (1) depression using a valid screening tool (1) depression using a valid screening tool (1) depression using a valid screening tool (1) Maximize coping skills (2) Maximize coping skills (2) Maximize coping skills (2) Maximize coping skills (2) Positive support system (2) Positive support system (2) Positive support system (2) Positive support system (2) Patient/program goal: Patient/program goal: Patient/program goal: Patient/program goal: Preventative medication: Preventative medication: Preventative medication: Preventative medication: Aspirin Y N Aspirin Y N Aspirin Y N Aspirin Y N Clopidogrel Y N Clopidogrel Y N Clopidogrel Y N Clopidogrel Y N Beta blockade Y N Beta blockade Y N Beta blockade Y N Beta blockade Y N ACE inhibitor Y N ACE inhibitor Y N ACE inhibitor Y N ACE inhibitor Y N Statin or other lipid lowering agent Y N Statin or other lipid lowering agent Y N Statin or other lipid lowering agent Y N Statin or other lipid lowering agent Y N Fall risk assess Y N Assistive device C W Wh/ch GB Session number: Session number: Session number: Session number: No changes, proceed with rehab Please add/change the following: Physician signature/date: Physician signature/date: Physician signature/date: Physician signature/date:

5 References AACVPR : Guidelines for Cardiac Rehabilitation Programs, ed. 4. Champaign, IL: Human Kinetics, 2004 AACVPR Core Competencies for Cardiac Rehabilitation Professional. (J. Cardipulmonary Rehabilitation 1994; 14:87-92) ACSM Guidelines for Graded Exercise Testing and Prescription, ed. 8. Baltimore, MD: Lipppincott Williams and Wilkins, ACSM Resource Manual for Guidelines for Exercise Testing and Prescription, ed. 5., Baltimore, MD: Lippincott Williams and Wilkins, AACVPR Cardiac Rehabilitation Resource Manual. Champaign, IL: Human Kinetics, ) AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services Thomas et al. Journal of Cardiopulmonary Rehabilitation and Prevention ) AHA/AACVPR Scientific Statement: Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update Balady G, Williams MA, Bittner V, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115: ) AACVPR Consensus Statement. Outcomes Evaluation in Cardiac Rehabilitation/Secondary Prevention Programs: Improving Patient Care and Program Effectiveness Sanderson BK, Southard D, Oldridge N. AACVPR consensus statement. Outcomes evaluation in cardiac rehabilitation/secondary prevention programs: improving patient care and program effectiveness. J Cardiopulm Rehabil 2004;24: ) AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2006 Update Smith SC Jr., Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol 2006;47: Key 6MWT=6 minute walk test Chol=cholesterol NA=salt HR=heart rate ft=feet HDL=high density lipids equip=equipment meds=medication CKD=chronic kidney disease LDL=low density lipids orient=orientation BP=blood pressure RPE=rate of perceived exertion Trig=triglycerides wm-up=warm up ex=exercise DOB=date of birth BS=blood sugar cl-dn=cool down s/s= signs and symptoms TM=treadmill freq=frequency act=action maint=maintenance B=bike cir=circumference DM=diabetes mellatis max=maximum STP= stepper BMI=basic metabolic index MET=metabolic equivalent A&P=anatomy and physiology EG=ergo meter wt=weight vs=visit psych=psychological EL=ellipiltical CAD=coronary artery disease ACE= angiotensin-converting enzyme FBS=fasting blood sugar R=rower m=male relap=relapse #=number Ht=height f=female prep=preparation amt=amount Y=yes N=no c=cane w=walker GB=gait belt wh/ch=wheel chair

Individual Pulmonary Treatment Plan rev 1/10 Name: DOB: Age: Date entered program: Diagnosis: Date of exacerbation: Allergies: Physician: Office vs:

Individual Pulmonary Treatment Plan rev 1/10 Name: DOB: Age: Date entered program: Diagnosis: Date of exacerbation: Allergies: Physician: Office vs: (Circle all BOLD that apply) (Circle all BOLD that apply)