Warfarin Record
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BRITISH COLUMBIA MEDICAL ASSOCIATION
ATTACH PATIENT INFORMATION LABEL HERE
WARFARIN PATIENT RECORD SHEET
PATIENT INFORMATION
Indications:
PHN
FIRST NAME (INITIALS)
SURNAME OF PATIENT
atrial fibrillation DVT/PE thrombophilia prosthetic heart valve intracardiac thrombus Other:
Please complete and indicate 1st and 2nd preference for contact
Target INR Range: 2.0 – 3.0 2.5 – 3.5 Other: Duration: 3 mos lifelong reassess when: Oral Anticoagulant: Coumadin
Other:
Tablet Strengths: 1 - pink 2 - lavender
___ Work Phone: ( ___ Home Phone: (
)
___ Cell: ___ Pager:
(
)
(
)
___ Fax: Email: ___
(
)
2.5 - green
4 - blue
6 - teal
3 - tan
5 - peach
7 - yellow
)
10 - white
OTHER INFORMATION NAME OF PRIMARY PHYSICIAN
TELEPHONE NUMBER
FAX
NAME OF SPECIALIST
TELEPHONE NUMBER
FAX
NAME OF SPECIALIST
TELEPHONE NUMBER
FAX
INR RESULTS ALSO COPIED TO:
DATE
FAX
LAB
Specimen Date
OTHER
PHARMACY
HB if done
PLTS if done
INR Result
Dosage Instruction
Weekly mg
Next INR
Date/Status of Patient Notification
MD Initials
Notifier Initials
D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S:
CONTINUED OVER
Specimen Date
HB if done
PLTS if done
INR Result
Dosage Instruction
Weekly mg
Next INR
Date/Status of Patient Notification
MD Initials D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S:
D: S:
Notifier Initials
ATTACH PATIENT INFORMATION LABEL HERE
WARFARIN PATIENT RECORD SHEET
PATIENT INFORMATION
Indications:
PHN
FIRST NAME (INITIALS)
SURNAME OF PATIENT
atrial fibrillation DVT/PE thrombophilia prosthetic heart valve intracardiac thrombus Other:
Please complete and indicate 1st and 2nd preference for contact
Target INR Range: 2.0 – 3.0 2.5 – 3.5 Other: Duration: 3 mos lifelong reassess when: Oral Anticoagulant: Coumadin
Other:
Tablet Strengths: 1 - pink 2 - lavender
___ Work Phone: ( ___ Home Phone: (
)
___ Cell: ___ Pager:
(
)
(
)
___ Fax: Email: ___
(
)
2.5 - green
4 - blue
6 - teal
3 - tan
5 - peach
7 - yellow
)
10 - white
OTHER INFORMATION NAME OF PRIMARY PHYSICIAN
TELEPHONE NUMBER
FAX
NAME OF SPECIALIST
TELEPHONE NUMBER
FAX
NAME OF SPECIALIST
TELEPHONE NUMBER
FAX
INR RESULTS ALSO COPIED TO:
DATE
FAX
LAB
Specimen Date
OTHER
PHARMACY
HB if done
PLTS if done
INR Result
Dosage Instruction
Weekly mg
Next INR
Date/Status of Patient Notification
MD Initials
Notifier Initials
D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S:
CONTINUED OVER
Specimen Date
HB if done
PLTS if done
INR Result
Dosage Instruction
Weekly mg
Next INR
Date/Status of Patient Notification
MD Initials D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S: D: S:
D: S:
Notifier Initials
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