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)

Related Articles

Ambulatory Specialty Model (ASM) | McGovern Medical School

(ASM) – Heart Failure | McGovern Medical School