8 survey

OMB# 0925-0491

EXPIRATION DATE XX/XXXX

expp. XX/XXXX

HEART FAILURE DIAGNOSIS FORM

EVENT-ID NUMBER: CONTACT NUMBER: FORM CODE:

VERSION: A DATE 11/07/2007

Instructions: Please complete the Heart Failure Diagnosis Form using the attached Event Summary Form and the medical reports provided to assign a heart failure diagnosis. If you mark an answer in error, mark an “X” through the incorrect answer and circle the appropriate response.

Part A: ADMINISTRATION INFORMATION

1

H

. a. Batch Number:

b. Type of Review: Original ……………..…….. O

Adjudication ………..……. A

Special review ………….... S

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c. Date of HDX completion:

2. Code number of person completion this form:

PART B: REVIEW OF COMPUTER’S HF DIAGNOSIS

YES NO UNKNOWN

3. Does this event meet criteria for complete chart abstraction? Y N U

4. Is there evidence of

a. Abnormal LV systolic function? Y N U

b. Abnormal RV systolic function: Y N U

c. LV diastolic dysfunction Y N U

5

. Estimated LVEF (worst): a. ≥ 50% b. 35-49% c. < 35% d. Unknown

6. Assign an overall heart failure diagnosis based on your clinical judgment (select only one)

Definite decompensated heart failure ………………………… A

Possible decompensated heart failure ………………………… B

Skip to Item 8

Chronic stable heart failure………………………………………. C

Skip to Item 8

Heart failure unlikely ……………………………………………… D

Skip to Item 8

Unclassifiable ……………………………………………………….. F

Yes NO UNKNOWN

a. Was definite or possible decompensated heart failure

present at admission? ……………………………………………………………. Y N U

Skip to Item 8

7 . Was this event fatal? ……………………………………………………………… Y N

a. Was decompensated heart failure the primary cause of death?......... Y N U

8. Comments: ___________________________________________________________________________________

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