Indications for Digoxin Blood Level Monitoring

Date of evaluation (enter MM/DD/YYYY)

Is the patient an inpatient or outpatient?

• no improvement or worsening of congestive heart failure?

• no improvement or worsening of atrial fibrillation or flutter?

• suspected noncompliance?

• concomittant use of an interacting drug?

• suspected malabsorption?

• a supraventricular tachycardia?

• an atrioventricular conduction defect?

• multifocal premature ventricular contractions?

• suspected overdosage?

• visual changes?

• anorexia, nausea or vomiting?

• diarrhea and/or abdominal pain?

• confusion and/or headache?

• unstable or declining renal function?

• a low serum potassium level?

• hypoxia?

• recent increase or change in diuretic dose?

• advanced age?

• hypothyroidism?

• magnesium depletion?

• hypercalcemia?

• an acute myocardial infarction or ischemia?

Has the patient been recently started on digoxin?

Has the patient had a recent change in digoxin dose?

Number of days since last change

Date that last available digoxin level available (enter MM/DD/YY)

Route of administration for last dose of digoxin

Number of hours since last dose