Anticoagulation

At goal / managed

G1 *Stable on warfarin, INR in range, no bleeding*	Anticoagulation-specific review completed alongside the cardiovascular examination in a patient on warfarin for atrial fibrillation. Point-of-care INR 2.6, within the ordered range; no bruising, bleeding gums, hematuria, melena, or unusual bleeding reported, and no falls or head injury. The patient reports consistent dosing and stable vitamin-K dietary intake. Findings indicate stable, therapeutic anticoagulation. RN-level assessment was required to confirm the INR against the ordered range and screen for thromboembolic and hemorrhagic complications. Bleeding precautions, interaction avoidance, vitamin-K consistency, and the INR schedule reinforced; teach-back accurate. Continued skilled monitoring indicated.
G2 *Stable on DOAC, adherent, renal function monitored*	Anticoagulation-specific review completed in a patient on a direct oral anticoagulant. The patient reports taking the medication at the prescribed times without missed doses; no bruising, gum bleeding, hematuria, or melena, and no falls. The ordered renal-function value was reviewed and is within parameters, supporting continued dosing. Findings indicate stable anticoagulation with preserved renal clearance. RN-level assessment was required to verify adherence given the short half-life and to screen for bleeding and thromboembolic complications and renal change. Adherence, bleeding precautions, and warning signs reinforced; teach-back accurate. Continued skilled monitoring indicated.
G3 *INR returned to range after dose adjustment*	Anticoagulation-specific review completed after a recent warfarin dose adjustment for an out-of-range INR. Repeat point-of-care INR 2.4, now within the ordered range; no bleeding or bruising reported and no falls. The patient verbalizes the adjusted dose and a consistent vitamin-K intake. Findings indicate a corrected, therapeutic INR. RN-level assessment was required to confirm the corrected INR and reinforce the factors that influence stability. The adjusted dose, vitamin-K consistency, interaction avoidance, and the recheck schedule reinforced; teach-back accurate. Continued skilled monitoring indicated.
G4 *Post-DVT on anticoagulation, no recurrence or bleeding*	Anticoagulation-specific review completed in a patient anticoagulated after a deep-vein thrombosis. No unilateral calf swelling, warmth, or tenderness and no dyspnea or chest pain (deep-vein-thrombosis and embolism surveillance documented in the Peripheral Vascular reference); no bruising or unusual bleeding and no falls. The patient reports adherence to the regimen. Findings indicate no recurrence and no bleeding. RN-level assessment was required to screen for recurrent thrombosis and hemorrhagic complications during the treatment course. Warning signs of recurrent thrombosis and pulmonary embolism and bleeding precautions reinforced; teach-back accurate. Continued skilled monitoring indicated.

Stable on warfarin, INR in range, no bleeding

Anticoagulation-specific review completed alongside the cardiovascular examination in a patient on warfarin for atrial fibrillation. Point-of-care INR 2.6, within the ordered range; no bruising, bleeding gums, hematuria, melena, or unusual bleeding reported, and no falls or head injury. The patient reports consistent dosing and stable vitamin-K dietary intake. Findings indicate stable, therapeutic anticoagulation. RN-level assessment was required to confirm the INR against the ordered range and screen for thromboembolic and hemorrhagic complications. Bleeding precautions, interaction avoidance, vitamin-K consistency, and the INR schedule reinforced; teach-back accurate. Continued skilled monitoring indicated.

Stable on DOAC, adherent, renal function monitored

Anticoagulation-specific review completed in a patient on a direct oral anticoagulant. The patient reports taking the medication at the prescribed times without missed doses; no bruising, gum bleeding, hematuria, or melena, and no falls. The ordered renal-function value was reviewed and is within parameters, supporting continued dosing. Findings indicate stable anticoagulation with preserved renal clearance. RN-level assessment was required to verify adherence given the short half-life and to screen for bleeding and thromboembolic complications and renal change. Adherence, bleeding precautions, and warning signs reinforced; teach-back accurate. Continued skilled monitoring indicated.

INR returned to range after dose adjustment

Anticoagulation-specific review completed after a recent warfarin dose adjustment for an out-of-range INR. Repeat point-of-care INR 2.4, now within the ordered range; no bleeding or bruising reported and no falls. The patient verbalizes the adjusted dose and a consistent vitamin-K intake. Findings indicate a corrected, therapeutic INR. RN-level assessment was required to confirm the corrected INR and reinforce the factors that influence stability. The adjusted dose, vitamin-K consistency, interaction avoidance, and the recheck schedule reinforced; teach-back accurate. Continued skilled monitoring indicated.

Post-DVT on anticoagulation, no recurrence or bleeding

Anticoagulation-specific review completed in a patient anticoagulated after a deep-vein thrombosis. No unilateral calf swelling, warmth, or tenderness and no dyspnea or chest pain (deep-vein-thrombosis and embolism surveillance documented in the Peripheral Vascular reference); no bruising or unusual bleeding and no falls. The patient reports adherence to the regimen. Findings indicate no recurrence and no bleeding. RN-level assessment was required to screen for recurrent thrombosis and hemorrhagic complications during the treatment course. Warning signs of recurrent thrombosis and pulmonary embolism and bleeding precautions reinforced; teach-back accurate. Continued skilled monitoring indicated.

1. Where this overlay applies

At goal / managed