Anticoagulation Reversal Assessment Form
Use this form to assess anticoagulant exposure, bleeding severity, objective findings, lab data, and reversal needs for a patient evaluation.
Patient and Encounter Information
Patient Name
First Name
Last Name
Preferred Identifier
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex/Gender
Female
Male
Intersex
Non-binary
Prefer to self-describe
Prefer not to say
Assessment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Facility / Department
*
Referring Clinician / Service
Reason for Assessment
*
Active bleeding
Urgent procedure
Trauma
Suspected overdose
Other clinical concern
Anticoagulant Exposure History
Is the patient currently taking any anticoagulant?
*
Yes
No
Unsure
Anticoagulant class
*
Vitamin K antagonist (warfarin)
Direct factor Xa inhibitor
Direct thrombin inhibitor
Heparin (unfractionated)
Low-molecular-weight heparin
Fondaparinux
Other prescribed anticoagulant
Specific anticoagulant agent(s)
*
Warfarin
Apixaban
Rivaroxaban
Dabigatran
Edoxaban
Heparin
Enoxaparin
Dalteparin
Fondaparinux
Other prescribed anticoagulant
Anticoagulant medication details
*
Duration of anticoagulant use
Any doses missed, delayed, or doubled?
No
Yes, missed doses
Yes, delayed doses
Yes, doubled doses
Yes, multiple types
Unsure
If yes, describe the dosing issue(s)
Approximate time since last anticoagulant dose
Clinical Presentation and Bleeding Assessment
Active bleeding present?
*
No
Yes
Suspected bleeding without confirmed source?
*
No
Yes
Urgent reversal needed before a procedure?
No
Yes
Overdose concern?
No
Yes
Bleeding site(s) or symptom category
*
Intracranial
Gastrointestinal
Urinary
Wound/Surgical
Mucosal
Other
Estimated bleeding severity or urgency
*
Mild
1
2
3
4
5
6
7
8
9
Critical
10
1 is Mild, 10 is Critical
Onset and time course
Sudden onset
Gradual onset
Intermittent
Persistent
Worsening
Improving
Approximate amount/persistence of bleeding
Minimal
Small but ongoing
Moderate
Heavy
Not measurable
Hemodynamic symptoms
Rows
Present
Dizziness
1
Syncope
2
Shortness of breath
3
Chest pain
4
Visible bleeding signs and whether bleeding has stopped
Rows
Present
Stopped
Bruising
5
6
Hematuria
7
8
Melena
9
10
Hematemesis
11
12
Vital Signs and Objective Findings
Blood pressure
Heart rate
Respiratory rate
Oxygen saturation (%)
Temperature (°C)
Mental status / alertness
Please Select
Alert
Verbal response
Pain response
Unresponsive
Other
Objective findings observed
Pallor
Active external bleeding
Swelling or hematoma
Neurological deficit
Signs of shock or poor perfusion
Other
Assessment status
*
Stable
Unstable
Requires emergency escalation
Laboratory and Diagnostic Data
Collection date/time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
INR
PT (seconds)
aPTT (seconds)
Hemoglobin / Hematocrit
Platelets (x10^3/µL)
Creatinine
Relevant imaging or diagnostic findings
Reversal Decision Factors
Is reversal fully indicated, partially indicated, or not yet determined?
*
Fully indicated
Partially indicated
Not yet determined
What is the planned procedure urgency?
*
Emergent
Urgent
Semi-urgent
Elective
No procedure planned
How urgent is intervention to achieve hemostasis or proceed with treatment?
*
Low urgency
1
2
3
4
5
6
7
8
9
Immediate
10
1 is Low urgency, 10 is Immediate
What is the target timing for reversal relative to the planned intervention?
Immediately
Within 1 hour
Within 2-4 hours
Within 24 hours
Timing not yet determined
Which thrombotic risk considerations are present?
Mechanical heart valve
Recent venous thromboembolism
Atrial fibrillation with high stroke risk
Recent acute coronary syndrome
Active malignancy
Known thrombophilia
Other
Does the patient have any of the following relevant history or conditions?
Prior thrombosis
Recent surgery
Recent trauma
Hepatic impairment
Renal impairment
Pregnancy or possible pregnancy
Known allergy or prior reaction to a reversal agent
None of the above
How would you rate the confidence that reversal is needed?
Very low
Low
Moderate
High
Very high
What is the current thrombotic risk level if reversal is given?
Low
Moderate
High
Very high
Please note any additional factors affecting the reversal choice.
Reversal Product Considerations
Intended reversal/supportive management plan
*
Vitamin K
4-factor PCC
PCC
Idarucizumab
Andexanet alfa
Protamine
Supportive care only
Transfusion support
Defer/consult specialist
Reversal agent status
*
Already administered
Planned
Pending approval
Not applicable
Concurrent supportive measures
IV fluids
Blood product transfusion
Local hemostatic measures
Mechanical compression
ICU monitoring
Specialist consultation
Other
Dose, timing, or administration notes
Contraindications or reasons for agent selection
Reversal product administration log
Consulting specialist service
Treatment Environment and Follow-up
Care Setting
*
Inpatient
Emergency Department
Outpatient
ICU
Other
Receiving Service
Monitoring Required
*
Yes
No
Repeat Lab Timing
Follow-up Assessment Date/Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Escalation Plan
Responsible Clinician
Submit Assessment
Should be Empty: