Anticoagulation Toolkit | 10.19.11 2

Warfarin Monitoring Sheet

Warfarin diagnosis: _______________________ Goal INR: __________________

Start date: _________ Stop date: _________ Education date: _______________

Annual review (due every 12 months after education date):__________________

Lab Topic Called/Draw Date INR Comments* New Dose Recheck INR Reviewed# Initials

*Comments:

• changes in diet • patient correctly states current dose • unusual bruising or bleeding• changes in medications • missed or extra doses in past week • assessment of altered INR

#Topics (one per month):

1. Mechanism, indication, duration, and goal INR2. Signs of bleeding and clotting3. Drug interactions; smoking and alcohol4. Dietary interactions5. Dosing: time of day, missed dose, tablet strength6. Out-of-town travel, procedures, and lab work

Patient name: __________________________________ MRN or Date of birth: _______________ Phone: ______________