Patient Consent Form American Academy of Home Care PhysiciansSpecial Consent for Anticoagulation Treatment I hereby authorize Dr. and such assistants as may be designated to prescribe and manage my anticoagulation medication. I understand that each person reacts differently to treatments and that the expected results of treatments cannot be guaranteed. My provider has discussed to my satisfaction, the nature and specifics of anticoagulation, the anticipated positive results of treatment, the recognized alternative forms of treatment, and the recognized risks and complications that could occur with either the agreed-upon form of anticoagulation or alternatives. Anticoagulation with warfarin: Nature and Specifics: The medication will be taken nightly, and the dose will be adjusted based on blood tests. Blood tests will be performed frequently at first (every day or every other day) and after a week or two will be performed less frequently (eventually every week to every month). Report to your provider any bleeding episodes during treatment (see below). Anticipated positive results include protection from or resolution of clotting of blood in the veins (thrombus) and protection from clots breaking off and producing damage to tissues (embolus). Recognized alternative treatments include intravenous heparin, low-molecular-weight heparin (LMWH), and an IVC filter. Risks of treatment: bleeding from gums, nose, cuts and/or bruising (minor bleeding) bleeding into internal organs, such as the intestines or brain (major bleeding) These are major complications and may result in disability or death. When properly managed, anticoagulation risk is about 5% for minor bleeding, and less than 1% for major bleeding. Anticoagulation with Low-Molecular Weight Heparin: Nature and Specifics: Medication will be given by subcutaneous injection once or twice daily. No blood tests are needed for this medication but blood tests will be required to monitor warfarin (coumadin) that is given at the same time. Report to your provider any bleeding episodes during treatment (see below). Anticipated positive results include protection from or resolution of clotting of blood in veins and arteries (thrombus) and protection from clots breading off and producing damage to tissues (embolus). Recognized alternative treatments include intravenous heparin, low-molecular-weight heparin (LMWH), and placement of an inferior vena cava (IVC) filter. Risks of treatment: bleeding from gums, nose, cuts and/or bruising (minor bleeding) bleeding into internal organs, such as the intestines or brain (major bleeding) These are major complications and may result in disability or death. When properly managed, anticoagulation risk is about 5% for minor bleeding, and less than 1% for major bleeding. Examples: Ms. G is elderly and home bound with severe heart failure, diabetes and emphysema. She has blood clots in the legs and wants treatment to prevent an embolus. She is willing to take subcutaneous injections (like her insulin) but doesn't want the hospitalization and multiple daily blood tests that are required when using standard, unfractionated heparin - she elects to take low-molecular-weight heparin at home. Anticoagulation Initiation/Contract of Therapy I understand that, as a participant in the anticoagulation program, I am required to participate willingly with all appointments and/or blood drawing. I understand that missing 3 consecutive blood draws may result in discharge from the anticoagulation program. I understand that I will call the anticoagulation program if I do not receive instructions within 48 hours after a blood draw. I am able to travel to the clinic for my appointments/blood draws or have made alternate plans for laboratory monitoring listed below. I understand the importance of being compliant with my warfarin dosage, having a consistent diet, and I will notify the clinic regarding all medication I am taking including over-the-counter drugs. I am taking a medicine that must be followed closely in order to protect me from any complications. I understand that noncompliance with any of the above can result in serious health risks and/or termination from the program. I have been given/offered the written patient information on enoxaparin and warfarin therapy and have been instructed on: Rational of therapy Potential drug interactions Activities Dietary considerations (including alcohol) Laboratory monitoring (INR) When to take doses What to do about missed doses Signs of over-anticoagulation Signs of disease recurrence What to do in case of bleeding Planned length of therapy Dose Alternate Blood Draw I understand that failure to comply with the above guidelines will result in my discharge from this anticoagulation program. Patient/Responsible Party Signature Date Anticoagulation Provider Date
I hereby authorize Dr. and such assistants as may be designated to prescribe and manage my anticoagulation medication. I understand that each person reacts differently to treatments and that the expected results of treatments cannot be guaranteed. My provider has discussed to my satisfaction, the nature and specifics of anticoagulation, the anticipated positive results of treatment, the recognized alternative forms of treatment, and the recognized risks and complications that could occur with either the agreed-upon form of anticoagulation or alternatives.
Anticoagulation with warfarin:
Nature and Specifics: The medication will be taken nightly, and the dose will be adjusted based on blood tests. Blood tests will be performed frequently at first (every day or every other day) and after a week or two will be performed less frequently (eventually every week to every month). Report to your provider any bleeding episodes during treatment (see below).
Anticipated positive results include protection from or resolution of clotting of blood in the veins (thrombus) and protection from clots breaking off and producing damage to tissues (embolus).
Recognized alternative treatments include intravenous heparin, low-molecular-weight heparin (LMWH), and an IVC filter.
Risks of treatment:
These are major complications and may result in disability or death. When properly managed, anticoagulation risk is about 5% for minor bleeding, and less than 1% for major bleeding.
Anticoagulation with Low-Molecular Weight Heparin:
Nature and Specifics: Medication will be given by subcutaneous injection once or twice daily. No blood tests are needed for this medication but blood tests will be required to monitor warfarin (coumadin) that is given at the same time. Report to your provider any bleeding episodes during treatment (see below).
Anticipated positive results include protection from or resolution of clotting of blood in veins and arteries (thrombus) and protection from clots breading off and producing damage to tissues (embolus).
Recognized alternative treatments include intravenous heparin, low-molecular-weight heparin (LMWH), and placement of an inferior vena cava (IVC) filter.
Examples: Ms. G is elderly and home bound with severe heart failure, diabetes and emphysema. She has blood clots in the legs and wants treatment to prevent an embolus. She is willing to take subcutaneous injections (like her insulin) but doesn't want the hospitalization and multiple daily blood tests that are required when using standard, unfractionated heparin - she elects to take low-molecular-weight heparin at home.
Alternate Blood Draw
I understand that failure to comply with the above guidelines will result in my discharge from this anticoagulation program.