SECTION .1600 – PATIENT ASSESSMENT

10a NCAC 14F .1601       PATIENT ASSESSMENT

(a)  Within five weeks of a patient's admission to the program, the interdisciplinary team shall complete and document a cardiac rehabilitation assessment.  At a minimum, the assessment shall include the components specified in this Rule.

(b)  Medical Assessment shall include:

(1)           cardiovascular evaluation as to present diagnosis, therapy, and a discharge summary of the patient=s last hospitalization; or

(2)           statement by referring physician as to present diagnosis, and therapy;

(3)           resting 12-lead ECG;

(4)           medical record documentation prior to or during the first exercise session of ECG, hemodynamic data, and the presence or absence of symptoms, preferably determined by a graded exercise test.  A graded exercise test shall not be required when deemed unnecessary by the patient's attending or personal physician or the program's medical director;

(5)           fasting blood chemistry, as indicated, to include total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, triglycerides, and other comparable measures; and

(6)           simple spirometry, if clinically indicated.

(c)  Physical Assessment shall include:

(1)           functional capacity as determined by measured or predicted equivalents (METs);

(2)           height, weight, or other anthropometric measures (i.e., body mass index, percent body fat, waist-to-hip ratio, girth measurements);

(3)           current and past exercise history; and

(4)           physical limitations and disabilities that may impact rehabilitation.

(d)  Nursing Assessment shall include:

(1)           coronary risk profile;

(2)           current symptoms such as angina or dyspnea, and recovery from recent cardiac events;

(3)           presence of comorbidities;

(4)           assessment of medications; and

(5)           educational needs.

(e)  Nutrition Assessment shall include:

(1)           review of medical history;

(2)           eating patterns as measured by a food diary or food frequency questionnaire;

(3)           fasting blood chemistries as described in Subparagraph (b)(5) of this Rule;

(4)           anthropometric measures as described in Subparagraph (c)(2) of this Rule;

(5)           behavioral patterns; and

(6)           identification of nutritional goals.

(f)  Mental Health Assessment shall include:

(1)           past history of mental illness including depression, anxiety, or hostility or anger; and

(2)           present mental health functioning and need for referral to a mental health professional.

(g)  Vocational Assessment shall include:

(1)           vocational questionnaire to determine current vocational status, description of physical requirements of job, working conditions, psychological demands as perceived by the patient; and

(2)           the need for vocational rehabilitation services.

History Note:        Authority G.S. 131E-169;

Eff. July 1, 2000;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 6, 2016.