Table 15. Form for managing anticoagulation during procedures/surgeries.
Section A Section B Patient name: . Age: Rec No: . . (Circle H or L) 1ry Diagnosis: Thrombo risk: H, L* Bleeding risk: H, L* 2ry Diagnosis: Thrombo risk: H, L* Bleeding risk: H, L* Procedure/surgery: Thrombo risk: H, L* Bleeding risk: H, L* Section C. Select the protocol - Plan 1, 2, 3, 4, 5 (Circle the number)
* H = high, Low = low.
(For more urgent surgery, please review Section Managing High INR or Bleeding, "8. Patient who requires more rapid or urgent reversal before procedure/surgery".)
1. Fill in the patient information in Section A. 1ry Diagnosis = Diagnosis that requires anticoagulation. 2ry Diagnosis = Diagnosis(es) that may increase thromboembolic or bleeding risks.
2. Determine thromboembolic and bleeding risk in Section B. Then circle the H (high) or L (low). Using Table 9, Table 11, Table 12. for risk stratification.
3. Select the protocol plan. Using Table 11, Table 12, Table 10, and individualization for selection guidelines. Then circle the protocol plan number in Section C.
4. May print "Managing anticoagulation during procedures/surgeries section". May also mark those areas picked (underline or yellow mark).May send this marked printout to primary physician or place it in the chart.