During the last decade many guidelines have been published for detection, evaluation and treatment of different cardiovascular disease (CVD) risk factors (RF) including hypertension (HTN), diabetes mellitus (DM), dyslipidemia, and obesity. Many of these were evidence-based, vigorously reviewed and regularly updated.

Nevertheless, guidelines were not sufficient to change neither the outcome nor the behavior of caregivers. Several studies have shown that clinicians often fail to collect, routinely, even basic information such as plasma lipids, blood pressure (BP) and cigarette smoking status during the course of medical care.[17,18]

This failure has been explained by many barriers, identified earlier. Among these are the lack of knowledge and poor communication skills of the practicing physicians, lack of self efficacy, oversight, discontinuity of care, lack of communication between providers caring for the same patient, lack of external barriers, lack of auditing, pressure of work, co-morbid illness, along with the diverse and complex work-up needed for chronic problems at different stages of their progress.[17,18,20,22] Practicing physicians may find this work-up time-consuming, [23] as most of the consultation time is spent in looking-up different pages in the medical chart, which might belong to previous visits in the last few months or even years, in order to find, compare and interpret laboratory results and blood pressure readings.

Another difficulty that may add to the burden is the need to reduce the risk for CVD which includes the recall of all necessary details needed for:[23]

1. the identification and measurement of RF and collection of clinical data relevant for assessing these factors;
2. the interpretation of risk-related data with estimation of total CVD risk, which is highly missed;
3. and the use of therapeutic intervention to minimize CVD risk or to prevent the development of additional RF.

The principle of assessing total risk associated with multiple CVD risk factors has been well stated since its first introduction in New Zealand in 1993, and followed thereafter, by many guidelines, worldwide. It provides more logical approach to patient management, as it approaches the whole patient and every aspect of his risk to develop CVD. It predicts short-term benefits and provides accurate data to substantiate a physician's clinical judgment. This is particularly true by identifying those individuals who, while asymptomatic, will potentially benefit from risk-reducing interventions.[26]

This article describes 4 pages of evidence-based encounter forms (EF) that have been developed by the author to facilitate office assessment, follow-up and audit of services delivered to patients with chronic CVD risk factors. They are used in the initial clinical assessment of patients presenting with high readings of BP, fasting blood sugar (FBS), total cholesterol or body mass index (BMI). In addition, they provide a tool for stratification of CVD risk, regular follow up and annual assessment.

The development of these forms started in the late 1990's. At that time, many constraints were noticed by the author regardingthe use of the locally available forms assigned, at that time, for the follow up of either hypertension or diabetes. Although, they had a significant advantage in auditing the work, they lacked convenience in office use. Their application involves extra work and time. Physicians need to go through many papers and forms to browse and fill. On the other hand, they do not offer any guide for initial assessment and do not consider all risk factors in one view.

On this background, the author started to look for the practice of other institutions, during his visits to different regions and countries, in addition to browsing for the internationally published ones. Unfortunately, none of these have been considered for use in neither initial CVD risk assessment nor the estimation of this risk. They were, merely, used in the follow up of either hypertensive or diabetic patients, which included ,their best, blood pressure readings, blood sugar, urine dipstick results, and/or medications.

The presently described EF have considered, in their design, the constraints and needs presented above, to be evidence-based and the need to have a total CVD risk assessment approach.

For these reasons, current local and international guidelines that consider detection, evaluation or management of CVD risk factors were reviewed and their recommendations were put in view.

EF, then, were put in practice and were periodically reviewed to meet up-to-date recommendations and goals of their development. The latest version was reviewed upon current guidelines, protocols, and references shown below, in addition to comments collected from practicing physicians and nurses.[1,2,3,4,5,6,7,8,9,10,11,29,33,39,41,43,44,45]

Figure 1 shows the temporal use of the described EF. The initial assessment visit needs the use of all four forms, while the regular follow-up visit necessitates the use of one form only. However, the annual assessment requires three of them to be used.

EF-1 (Figure 2) is the initial-visit assessment form. It is intended for use in the initial assessment of newly attending patients with CVD risk factors, mentioned above. It contains eight sections for demographic data, history taking, physical examination and investigations. It assists in identifying confounding RF, target organ damages (TOD), associated clinical conditions (ACC) and secondary causes such as renal, vascular and endocrine diseases. In addition, a table has been included to help in staging the BP level.

EF-2 (Figure 3) is the CVD risk stratification form. It is tailored to supplement both EF-1 and EF-4. It helps summarize and stratify CVD risk. The risk assessment tool, presented in the European guidelines for management of hypertension, was used for this purpose.3 Two tables are provided in this EF; the first table provides a check list of RF, TOD and ACC collected, earlier, using EF-2 or EF-4. This list makes stratification of total CVD risk easier, using the second table. EF-2 might be filled in by the physician or the attending nurse.

On the other hand, EF-2 provides a chance to compare the progress in total CVD risk among the years of follow-up.

EF-3 (Figure 4) is the regular follow-up flow chart. It is used in each visit the patient pays to the clinic. It contains four sections and 14 columns. Each column is intended for use in one visit. One section has reserved spaced for more frequently monitored parameters, i.e. vital signs, urinary dipstick and blood chemistry. These help in monitoring the control and early detection of hemodynamic - and biochemical drug adverse effects. The uppermost section is allocated for plotting blood pressure readings. It allows for quick evaluation of control of BP over the last few visits. Documentation of medication refills and changes in dose requirement are possible for six medications, each in one line.

Patient's compliance is readily reviewed and documented using a mnemonics (DEMO) created for this purpose, where D, E, M and O stand for diet, exercise, medication and others (such as smoking, hygiene and foot care), respectively. In the same pattern health education is reviewed and documented. DEMO functions as a reminder for the physician to inquire about patient's compliance and to provide appropriate education.

Advantages of the use of CVR Encounter Forms.

1. Facilitate and empower initial assessment and follow-up of different CVD risk factors in one common form.
2. Simplify stratification of CVD risk, and thus approaching patients more appropriately.
3. Minimize the time needed in assessment and follow-up.
4. Enable physicians to compare the status of current visit with previous visits and identify defect in service and control, easily. The comparison can be used as reflection that can be shown to patients to help them improving their compliance.
5. Function as a reminder for care. They prompt care giver to address this issue during every visit, even if the patient is presenting for unrelated complaint, such as cut wounds.
6. Improve quality of service, documentation and ensure uniform data entry.
7. Facilitate communication between providers caring for the same patient.
8. Facilitate the audit work in readily structured process.

Decision of referral to other services such as nephrology, dietary, ophthalmology, or echocardiography can be documented in an exclusive field in the lower part of the form. At the bottom, two fields were allocated for extra notes, such as reason to change regimen, and expected next visit.

The last form EF-4 (Figure 5) is the annual assessment chart. It acts as a reminder for the annual work-up needed for CVD risk patients and provides, in addition, a tool to compare progress in control of risk, development of TOD and complications, as well as hemodynamic and biochemical changes secondary to medications used. Parameters needed for estimation of CVD risk are labeled by a super text. Additionally this form is used, by the auditors to evaluate process and outcome achieved.

Many advantages have been noticed by the author from the use of EF-1 through to EF-4 (box 1). However, the extra use of such forms necessitated regular update and regular orientation for newly employed staff, which were, thankfully, encouraging for the development of the forms.

In conclusion, caring for patients with multiple CVD risks is a demanding task that physicians usually fail to fulfill, as per guidelines. This article describes the development of evidence-based encounter forms that help physicians and nurses to put guidelines into practice. Validation of these forms on a wider scale is needed to show their significance.

The author would like to thank all physicians and nurses who have relayed their comments and suggestions on the content and design of the forms. Particular thanks to Rania Al-Mousa, RN, Dr. Fatima Al-Dubaisi and Dr. Mohammed Al-Zaher for their valuable comments. Thanks are extended to my sincere students Zainab Al-Duhaileb and Jumana Al-Jishi for their editing support. Special appreciation for my wife Azhar Al-Juma and my daughter Fatima for their valuable design support.