Heart Failure – Documentation Checklist
Prepare for the Heart Failure ASM model with this practical checklist focused on documentation, care management, and performance readiness.
High-Risk ASM Audit Deficiencies
Heart Failure
❌ “CHF stable” with no symptom assessment
❌ No EF documented
❌ No explanation for missing or suboptimal GDMT
❌ No evidence of care coordination
❌ Repeated follow-up notes with no active management
Document Disease Identification
☐ HF type documented:
- HFrEF
- HFmrEF
- HFpEF
☐ Acuity documented:
- Acute
- Chronic
- Acute on Chronic
☐ Etiology documented when known:
- Ischemic
- Hypertensive
- Valvular
- Nonischemic cardiomyopathy
- Other
☐ Most recent EF documented or referenced
☐ NYHA Functional Class documented (if known)
Current Clinical Status
☐ Symptoms documented
Examples:
- Dyspnea
- Orthopnea
- PND
- Fatigue
- Exercise intolerance
☐ Symptom severity documented
☐ Weight changes documented
☐ Edema assessment documented
☐ Volume status documented
Examples:
- Euvolemic
- Hypervolemic
- Volume overloaded
Guideline Directed Medical Therapy (GDMT)
☐ Medication regimen reviewed
☐ Documentation of GDMT classes when applicable:
- ARNI/ACEI/ARB
- Evidence-based beta blocker
- MRA
- SGLT2 inhibitor
☐ Medication changes documented
☐ Dose titration efforts documented
☐ Contraindications documented
☐ Medication intolerance documented
☐ Patient refusal documented when applicable
Audit Risk: Failure to explain why guideline-directed therapy is absent or not optimized.
Diagnostic Review
☐ Echocardiogram results reviewed
☐ Relevant lab studies reviewed
- BNP/NT-proBNP
- BMP/CMP
- Renal function
- Electrolytes
☐ Other cardiac testing reviewed when relevant
Care Coordination
☐ PCP communication documented
☐ Home health involvement documented
☐ Cardiac rehabilitation discussed/referred
☐ Electrophysiology referral discussed
☐ Advanced HF referral discussed when appropriate
☐ Hospital discharge follow-up documented
Risk Assessment and Plan
☐ Current stability addressed
☐ Hospitalization/readmission risk addressed
☐ Signs of decompensation discussed
☐ Follow-up interval justified
☐ Specific treatment goals documented
“ASM Gold Standard” Statement
Provider documentation should answer:
“What is this patient’s current heart failure status, what evidence-based therapy are they receiving, and what am I doing today to improve outcomes or prevent hospitalization?”
Readiness Tools
CMS ASM Readiness Guide(external link)