142 Adult Heart and HeartLung Status 3 Criteria 5 Extension

Adult Heart and HeartLung Status 3 Criteria 5 Extension Justification Form Medical Urgency Data
Fields to be completed by members
Form Section	Field Label	Notes
Status 3 Extension Criteria 5	Mechanical circulatory support device (MCSD) with right heart failure
Status 3 Extension Criteria 5	Dobutamine
Status 3 Extension Criteria 5	Dobutamine - Date of Initiation
Status 3 Extension Criteria 5	Dopamine
Status 3 Extension Criteria 5	Dopamine - Date of Initiation
Status 3 Extension Criteria 5	Epinephrine
Status 3 Extension Criteria 5	Epinephrine - Date of Initiation
Status 3 Extension Criteria 5	Milrinone
Status 3 Extension Criteria 5	Milrinone - Date of Initiation
Status 3 Extension Criteria 5	Inhaled nitric oxide
Status 3 Extension Criteria 5	Inhaled nitric oxide - Date of Initiation
Status 3 Extension Criteria 5	Intravenous prostacyclin
Status 3 Extension Criteria 5	Intravenous prostacyclin - Date of Initiation
Status 3 Extension Criteria 5	Pulmonary capillary wedge pressure
Status 3 Extension Criteria 5	Pulmonary capillary wedge pressure - Test Date
Status 3 Extension Criteria 5	Pulmonary capillary wedge pressure - Test Time
Status 3 Extension Criteria 5	Central venous pressure
Status 3 Extension Criteria 5	Central venous pressure - Test Date
Status 3 Extension Criteria 5	Central venous pressure - Test Time
Status 3 Extension Criteria 5	Extending the candidate status under criteria 5
Status 3 Extension Criteria 5	Dobutamine
Status 3 Extension Criteria 5	Dobutamine - Date of Initiation
Status 3 Extension Criteria 5	Dopamine
Status 3 Extension Criteria 5	Dopamine - Date of Initiation
Status 3 Extension Criteria 5	Epinephrine
Status 3 Extension Criteria 5	Epinephrine - Date of Initiation
Status 3 Extension Criteria 5	Milrinone
Status 3 Extension Criteria 5	Milrinone - Date of Initiation
Status 3 Extension Criteria 5	Inhaled nitric oxide
Status 3 Extension Criteria 5	Inhaled nitric oxide - Date of Initiation
Status 3 Extension Criteria 5	Intravenous prostacyclin
Status 3 Extension Criteria 5	Intravenous prostacyclin - Date of Initiation
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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