Anticoagulation

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Trace DC32-3

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1. Where this overlay applies

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2. Plan-of-care goals — provider parameters govern

The patient-specific, provider-ordered parameters always control. Record them first; the goals that follow are completed with the patient's actual ordered values, and every threshold elsewhere in this overlay defers to these orders.

▶ Provider-ordered parameters — record before charting goals

Anticoagulant and indication: ______ (warfarin / apixaban / rivaroxaban / dabigatran / edoxaban) for ______ (atrial fibrillation / venous thromboembolism / mechanical valve).

Target INR range (warfarin): ______ to ______.

INR-monitoring schedule (warfarin): ______; renal-function monitoring schedule (DOAC): ______.

Bleeding-precaution parameters and what to report: ______.

Hold or reversal orders and parameters: ______.

Plan-of-care goal templates

Edit each goal to the patient's ordered values and target dates.

  • Patient will maintain INR within the ordered range (______ to ______) if on warfarin, verbalizing the monitoring schedule and bleeding precautions, by [date].
  • Patient and caregiver will demonstrate bleeding-precaution practices and warning-sign recognition with teach-back ≥ 90% by [date].
  • Patient will adhere to the anticoagulant regimen and avoid interacting medications and foods, verbalizing the plan, by [date].
  • Patient will remain free of major bleeding and thromboembolic events through the certification period.
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