Warfarin Care Hospital Discharge

(For patients who are already enrolled on the Warfarin Care programme only)

Patient First Name *

Patient Surname *

Patient DOB *

Patient State *

Hospital *

Hospital Ward *

Admission Date *

Discharge Date *

Admitting Consultant *

Patients reason for admission to hospital *

Did the patient cease warfarin? *

Yes

Did the patient have Vitamin K in hospital? *

Yes

What date did the patient recommence Warfarin?

Was the patient given Clexane in hospital? *

Yes

Does the patient have any new medication / antibiotics? *

Target range? * (NB Warfarin Care requires a target range of one whole unit)

INR test dates and warfarin doses

INR

Dose

Date

INR

Dose

Date

INR

Dose

Date

INR

Dose

Date

INR

Dose

Discharge dose given? *

Yes

Please ensure the patient tests within the next three (3) days.

Completed By *

Completed on