Post-CABG Cardiac Rehabilitation Assessment & Exercise Planning Sheet

Form Filling and Clinical Assessment Guidance for Physiotherapists

Purpose of the Form

This assessment sheet is designed to guide safe, structured, and individualized cardiac rehabilitation following Coronary Artery Bypass Grafting (CABG). It integrates medical review, pre-exercise screening, functional capacity assessment, physiological monitoring, and exercise planning into a single clinical document.

The form supports:

  • Risk stratification before exercise
  • Baseline functional assessment
  • Objective exercise prescription
  • Ongoing monitoring and progression
  • Medico-legal documentation of cardiac rehabilitation care

Patient Identification Section

Fields to complete

  • Patient Name
  • UHID
  • Date
  • Referred By

Assessment Guidance

These details ensure accurate patient identification, continuity of care, and traceability. The referral source (cardiologist, cardiac surgeon, intensivist) provides context regarding clinical expectations and precautions.

Always verify patient identity using institutional protocols before assessment.

1. Medical & Clinical Review

Review of Medical Records & Procedure Notes

What to assess

  • Date of CABG surgery
  • Number of grafts and vessels involved
  • Surgical approach (median sternotomy)
  • Post-operative complications (arrhythmias, infections, prolonged ventilation)
  • Current cardiac status (LVEF, rhythm stability if available)

How to fill
Summarize only clinically relevant points that influence exercise safety and tolerance. Avoid copying entire discharge summaries.

Clinical significance
This review determines baseline risk, exercise intensity limits, and the need for strict sternal precautions.

Current Medications

What to assess

  • Beta-blockers
  • Antiplatelets / anticoagulants
  • ACE inhibitors / ARBs
  • Diuretics
  • Insulin or oral hypoglycemics

How to fill
List medications relevant to exercise response.

Clinical significance
Medications directly affect heart rate response, blood pressure behavior, fatigue, and exercise tolerance. For example, beta-blockers blunt heart rate response, making Borg RPE essential.

2. Screening & Pre-Exercise Checklist

Specific Clinical Considerations

What to assess

  • Diabetes (risk of hypoglycemia)
  • Sternal precautions
  • Hypertension
  • Obesity
  • Peripheral vascular disease

How to fill
Document all factors that require exercise modification or close monitoring.

Clinical significance
These considerations guide exercise selection, posture, resistance limits, and monitoring frequency.

Limitations to Movement or Exercise

What to assess

  • Shoulder or thoracic pain
  • Sternal instability
  • Lower limb weakness
  • Balance issues
  • Dyspnea on minimal exertion

How to fill
Briefly describe functional or mechanical restrictions.

Clinical significance
Identifies contraindicated movements and the need for seated or supported exercises.

3. Functional Capacity / Sub-Maximal Exercise Testing

Baseline Parameters

What to assess

  • Resting blood pressure
  • Resting heart rate
  • Resting oxygen saturation (SpO₂)

How to fill
Record values after the patient has rested quietly for at least 5 minutes.

Clinical significance
These values serve as baseline comparators during exercise and recovery phases.

Borg Rating of Perceived Exertion (RPE)

What to assess
Explain the Borg scale clearly to the patient before testing.

How to fill
Record Borg scores:

  • At rest
  • At 1 minute of activity
  • At 3 minutes of activity

Clinical significance
RPE is essential in post-CABG rehabilitation, especially when heart rate response is unreliable due to medications.

Target training zone typically corresponds to Borg 13–15.

4. Target Heart Rate Calculation (Karvonen’s Formula)

Step-by-Step Guidance

Fields to complete

  • Resting heart rate
  • Estimated maximum heart rate (220 – age)
  • Heart rate reserve (HRR)
  • Target heart rate range (usually 60–70% HRR in early rehab)

How to fill
Perform calculations carefully and document both lower and upper target limits.

Clinical significance
Provides an objective physiological framework for exercise prescription while maintaining safety.

Always cross-check target HR with symptoms and Borg RPE.

5. Exercise Circuit Plan

This section translates assessment findings into a structured exercise session.

A. Warm-Up Phase (2–3 minutes)

What to include

  • Breathing exercises
  • Gentle shoulder movements
  • Marching in place (if tolerated)

How to fill
Tick exercises that are safe and appropriate for the patient.

Clinical significance
Warm-up reduces cardiac load spikes and prepares musculoskeletal and respiratory systems.

B. Exercise Phase

Fields to complete

  • Duration of exercise phase
  • Target heart rate range
  • Borg RPE range (13–15)

What to assess
Select exercises based on:

  • Sternal precautions
  • Functional capacity
  • Balance and endurance

How to fill
Tick only exercises actually performed.

Clinical significance
Ensures exercise intensity remains within therapeutic and safe limits.

C. Cool-Down Phase (2–3 minutes)

What to include

  • Slow breathing
  • Gentle limb movements
  • Stretching

Clinical significance
Prevents post-exercise hypotension and arrhythmias.

D. Recovery Phase (1–2 minutes)

What to assess

  • Heart rate reduction below target
  • Borg RPE reduction to 11–13

Clinical significance
Confirms appropriate cardiovascular recovery and exercise tolerance.

6. Therapist’s Notes & Plan

Progression Plan / Modifications

What to document

  • Planned increase in duration or intensity
  • Exercise substitutions
  • Regression due to symptoms

Clinical significance
Provides continuity and justification for progression decisions.

Patient Response to Exercise / Symptoms Observed

What to assess

  • Fatigue
  • Dyspnea
  • Chest discomfort
  • Dizziness
  • Excessive BP or HR response

Clinical significance
Immediate documentation supports clinical safety and informs future session planning.

Therapist Authentication

Fields

  • Therapist name
  • Signature
  • Date

Clinical significance
Establishes professional accountability and medico-legal validity of the rehabilitation session.

Clinical Summary

The Post-CABG Cardiac Rehabilitation Assessment & Exercise Planning Sheet functions as a risk-controlled exercise prescription and monitoring tool. Accurate form filling requires:

  • Sound cardiovascular clinical reasoning
  • Understanding of pharmacological influences
  • Competence in physiological monitoring
  • Patient-centered exercise selection

When used consistently, this form enhances safety, standardization, and outcome-oriented cardiac rehabilitation practice

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