HEARTLAND Protocol FHIR Implementation Guide
0.1.0 - ci-build
HEARTLAND Protocol FHIR Implementation Guide
0.1.0 - ci-build
HEARTLAND Protocol FHIR Implementation Guide - Compilação de desenvolvimento local (v0.1.0) construída pelas ferramentas de compilação FHIR (HL7® FHIR® Standard). Veja o Diretório de versões publicadas
{
"resourceType" : "CarePlan",
"id" : "CarePlanExampleTier2",
"meta" : {
"profile" : [
🔗 "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-careplan"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Narrativa gerada: CarePlan CarePlanExampleTier2</b></p><a name=\"CarePlanExampleTier2\"> </a><a name=\"hcCarePlanExampleTier2\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Perfil: <a href=\"StructureDefinition-heartland-careplan.html\">HEARTLAND Care Plan</a></p></div><p><b>HEARTLAND Facility Implementation Tier</b>: <span title=\"Códigos:{https://fhir.heartlandprotocol.org/CodeSystem/heartland-implementation-tier tier-2-standard}\">Tier 2 - Standard</span></p><p><b>HEARTLAND Monitoring Track Assignment</b>: <span title=\"Códigos:{https://fhir.heartlandprotocol.org/CodeSystem/heartland-monitoring-track analog-track-b}\">Analog Track B</span></p><p><b>status</b>: Active</p><p><b>intent</b>: Plan</p><p><b>subject</b>: <a href=\"Patient-PatientExampleRural.html\">Rural Patient Example Female, DoB: 1947-06-15 ( https://fhir.heartlandprotocol.org/sid/example-mrn#EXAMPLE-001)</a></p><p><b>period</b>: 2026-04-16 --> 2026-07-16</p><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Scheduled[x]</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Not Started</td><td>Uma vez</td><td>Initiate all 4 GDMT classes (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2i) within 14 days per Tier 2 protocol. Prioritize SGLT2i and beta-blocker first if simultaneous initiation not feasible.</td></tr></table></blockquote><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Scheduled[x]</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Scheduled</td><td>Uma vez</td><td>Post-discharge contact within 48 hours by RN champion.</td></tr></table></blockquote><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Scheduled</td><td>7-day in-person follow-up visit at FQHC for vitals, medication reconciliation, and GDMT titration.</td></tr></table></blockquote><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Scheduled[x]</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Scheduled</td><td>Contagem 4 times, Uma vez por 1 week</td><td>Weekly follow-up phone calls x 4 weeks (Track B analog) capturing weight, blood pressure, oxygen saturation, and symptom assessment.</td></tr></table></blockquote><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Scheduled</td><td>Full discharge teach-back covering 8 AHA-aligned domains: (1) daily weight monitoring, (2) sodium and fluid restriction (<=2 g/day Na, 1.5-2 L fluid), (3) medication adherence and timing, (4) symptom recognition (red flags), (5) activity and exercise progression, (6) when to call provider vs ED, (7) follow-up appointment plan, (8) self-care between visits.</td></tr></table></blockquote><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Scheduled</td><td>Patient assistance program (PAP) pursuit + Generic Bridge for medication access. Generic therapy is superior to no therapy; never delay treatment while waiting for paperwork.</td></tr></table></blockquote><p><b>note</b>: </p><blockquote><div><p>Tier 2 protocol: full implementation over 12 months with phased rollout. Quality metrics: dose optimization and 30-day readmission reduction.</p>\n</div></blockquote></div>"
},
"extension" : [
{
"url" : "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-facility-tier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://fhir.heartlandprotocol.org/CodeSystem/heartland-implementation-tier",
"code" : "tier-2-standard",
"display" : "Tier 2 - Standard"
}
]
}
},
{
"url" : "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-monitoring-track-ext",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://fhir.heartlandprotocol.org/CodeSystem/heartland-monitoring-track",
"code" : "analog-track-b",
"display" : "Analog Track B"
}
]
}
}
],
"status" : "active",
"intent" : "plan",
"subject" : {
🔗 "reference" : "Patient/PatientExampleRural"
},
"period" : {
"start" : "2026-04-16",
"end" : "2026-07-16"
},
"activity" : [
{
"detail" : {
"status" : "not-started",
"scheduledTiming" : {
"repeat" : {
"boundsPeriod" : {
"start" : "2026-04-16",
"end" : "2026-04-30"
}
}
},
"description" : "Initiate all 4 GDMT classes (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2i) within 14 days per Tier 2 protocol. Prioritize SGLT2i and beta-blocker first if simultaneous initiation not feasible."
}
},
{
"detail" : {
"status" : "scheduled",
"scheduledTiming" : {
"repeat" : {
"boundsPeriod" : {
"start" : "2026-04-16",
"end" : "2026-04-18"
}
}
},
"description" : "Post-discharge contact within 48 hours by RN champion."
}
},
{
"detail" : {
"status" : "scheduled",
"description" : "7-day in-person follow-up visit at FQHC for vitals, medication reconciliation, and GDMT titration."
}
},
{
"detail" : {
"status" : "scheduled",
"scheduledTiming" : {
"repeat" : {
"count" : 4,
"frequency" : 1,
"period" : 1,
"periodUnit" : "wk"
}
},
"description" : "Weekly follow-up phone calls x 4 weeks (Track B analog) capturing weight, blood pressure, oxygen saturation, and symptom assessment."
}
},
{
"detail" : {
"status" : "scheduled",
"description" : "Full discharge teach-back covering 8 AHA-aligned domains: (1) daily weight monitoring, (2) sodium and fluid restriction (<=2 g/day Na, 1.5-2 L fluid), (3) medication adherence and timing, (4) symptom recognition (red flags), (5) activity and exercise progression, (6) when to call provider vs ED, (7) follow-up appointment plan, (8) self-care between visits."
}
},
{
"detail" : {
"status" : "scheduled",
"description" : "Patient assistance program (PAP) pursuit + Generic Bridge for medication access. Generic therapy is superior to no therapy; never delay treatment while waiting for paperwork."
}
}
],
"note" : [
{
"text" : "Tier 2 protocol: full implementation over 12 months with phased rollout. Quality metrics: dose optimization and 30-day readmission reduction."
}
]
}