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SPECIAL AUTHORITY REQUEST DALTEPARIN OR TINZAPARIN FOR TREATMENT OF VENOUS THROMBOEMBOLISM IN CANCER PATIENTS HATH 5469 Rev. 2017/01/12 For up to date criteria and forms, please check: www.gov.bc.ca/pharmacarespecialauthority
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How to fill out 5469 - venous thromboembolism
How to fill out 5469 - venous thromboembolism
01
To fill out 5469 - venous thromboembolism, follow these steps:
02
Start by providing the patient's personal information, such as their name, date of birth, and contact details.
03
Indicate the date the form is being filled out and any relevant identification numbers.
04
Specify the medical history of the patient, including any past venous thromboembolism incidents.
05
If applicable, mention any pre-existing conditions or risk factors that may contribute to venous thromboembolism.
06
Document the symptoms experienced by the patient, noting the duration and severity of each symptom.
07
Include the results of any diagnostic tests performed, such as ultrasounds or blood tests.
08
Provide information about any ongoing treatments or medications the patient is currently receiving.
09
If relevant, describe any preventative measures or lifestyle changes recommended for the patient.
10
Finally, sign and date the form to authenticate the information provided.
11
Remember to review the filled form for accuracy and completeness before submitting it.
Who needs 5469 - venous thromboembolism?
01
5469 - venous thromboembolism form is required for individuals who meet the following criteria:
02
- Patients with a suspected or confirmed diagnosis of venous thromboembolism.
03
- Individuals at risk of developing venous thromboembolism, such as those with a family history of the condition or who have undergone certain surgeries or medical procedures.
04
- Patients undergoing or planning to undergo specific treatments or procedures that carry a higher risk of venous thromboembolism, such as major orthopedic surgeries or cancer treatments.
05
- Individuals with symptoms suggestive of venous thromboembolism, such as leg pain, swelling, or shortness of breath.
06
- Healthcare professionals involved in the diagnosis, treatment, or monitoring of patients with venous thromboembolism.
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What is 5469 - venous thromboembolism?
5469 - venous thromboembolism is a form used to report cases of venous thromboembolism, a condition where blood clots form in the deep veins of the body.
Who is required to file 5469 - venous thromboembolism?
Healthcare providers and facilities are required to file 5469 - venous thromboembolism when a case is diagnosed or treated.
How to fill out 5469 - venous thromboembolism?
5469 - venous thromboembolism can be filled out electronically or on paper, following the specific instructions provided by the reporting authority.
What is the purpose of 5469 - venous thromboembolism?
The purpose of 5469 - venous thromboembolism is to track and monitor cases of venous thromboembolism for public health purposes.
What information must be reported on 5469 - venous thromboembolism?
Information such as patient demographics, diagnosis, treatment, and outcomes must be reported on 5469 - venous thromboembolism.
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