Anticoagulation Management Note (Warfarin/DOAC)

Date/Time of Service: [date and time]

Encounter Type: [in-person / video / phone / message]

Patient: [name], [DOB]

Anticoagulant Managed: [warfarin / apixaban / rivaroxaban / dabigatran / edoxaban]

Reason for Encounter: [INR review / DOAC follow-up / peri-procedural plan / bleeding concern / initiation / dose adjustment]

(Use mg and mL; use leading zeros for decimals, e.g., 0.5 mg; avoid trailing zeros. Omit sections or bullets not relevant to the current encounter.)

Anticoagulation Summary

Indication: [AF / VTE treatment / VTE secondary prevention / mechanical valve] (For AF, include CHA₂DS₂-VASc score with individual components; for VTE, specify event type, date, and provoked vs unprovoked.)

Current regimen: [medication], [dose] mg, [frequency], started [date] (For warfarin, include tablet strength(s) on hand.)

Target intensity: [INR goal range] (Include only for warfarin.)

Intended duration: [defined treatment duration or reassessment plan]

Interval History

[Anticoagulation-relevant interval history since last contact] (2–5 sentences addressing: adherence issues including missed/extra doses and timing; bleeding symptoms with severity and trend; thrombotic symptoms; new medications including OTC, herbals, and interacting drugs; diet or illness changes if on warfarin; planned procedures with date and bleeding risk. Use patient quotes for high-stakes facts. State explicitly if adherence was not assessed and why.)

Objective

(Include only data that informed today's decisions.)

• Warfarin: INR [value] ([date], [lab / POC / home]); trend: [last 2–4 INR values with dates]; TTR [percentage over interval] (Include TTR only if relevant to decisions.); [CBC/Hgb if bleeding concern] (Include this bullet only if managing warfarin.)
• DOAC: Cr [value] ([date]), CrCl [value] mL/min by [method]; [hepatic function if relevant to dosing]; [CBC/Hgb if bleeding concern or surveillance due] (Include this bullet only if managing a DOAC.)
• Shared: [weight if dose-reduction criteria apply]; [BP if uncontrolled hypertension affects bleeding risk]
• [Lab] required for safe dosing—ordered; interim plan: [description] (Include only if key lab is missing.)

Assessment

[Current anticoagulant status: therapeutic/subtherapeutic/supratherapeutic INR for warfarin; appropriate vs potentially inappropriate DOAC dose based on renal function]

[Key drivers of current status or needed changes: adherence, drug interaction, dietary change, renal decline, planned procedure]

[Active bleeding or thrombosis concerns requiring escalation] (Include only if present.)

Plan

Anticoagulation management

• Warfarin dose instruction: (Include only if managing warfarin.)
  • Tablet strength(s): [tablet strength(s) on hand]
  • Daily schedule: Mon [dose] mg; Tue [dose] mg; Wed [dose] mg; Thu [dose] mg; Fri [dose] mg; Sat [dose] mg; Sun [dose] mg
  • Total weekly dose: [total] mg/week
  • Rationale: [link to INR, trend, interactions, or clinical context]
  • Out-of-range response: [hold doses / vitamin K dose and route / escalation] (Include only if responding to out-of-range INR.)
  • Bridging: [indicated / not indicated]; rationale: [reasoning]; [agent, dose, duration if bridging] (Include only if bridging considered.)
  • Next INR: [date or interval]
• DOAC dosing: [medication], [dose] mg, [frequency] is [appropriate / potentially inappropriate] (Include only if managing a DOAC.)
  • Rationale: [indication, age, weight, renal function, interacting meds supporting current dose]
  • Adjustment: [no change / change to new dose with rationale]
  • Monitoring: Next renal function and CBC: [date or interval] (Use shorter interval if elderly, frail, or CrCl ≤60 mL/min.)
  • Interaction management: [actions taken] (Include only if applicable.)
• Peri-procedural management: (Include only if procedure planned.)
  • Procedure: [name], [date], bleeding risk: [low / intermediate / high]
  • Hold plan: Last dose [timing] (Account for renal clearance for DOACs.)
  • Pre-procedure INR: [check date and threshold] (Include only for warfarin.)
  • Restart plan: [timing contingent on hemostasis confirmation]
  • Coordination: [communication with procedural team and patient]
• Education provided: [topics covered: indication, adherence, bleeding precautions, interaction avoidance, follow-up]; teach-back: [patient verbalized understanding / not performed] (If education deferred, note what was deferred, when it will be completed, and interim safety instructions.)
• Escalation instructions: Seek urgent care for head trauma, major bleeding, neurologic symptoms, melena, hematemesis; after-hours contact: [instructions]
• Orders and coordination: [labs ordered with timing]; [prescriptions sent]; [messages to other clinicians]; patient contact: [reached / voicemail / portal message]

[Additional problem]

(Include only if secondary problem requires separate documentation, e.g., drug interaction, bleeding event, adherence barrier.)

• Assessment: [problem-focused assessment]
• Plan: [targeted actions and follow-up]