@prefix fhir: . @prefix owl: . @prefix rdf: . @prefix rdfs: . @prefix xsd: . # - resource ------------------------------------------------------------------- a fhir:CarePlan ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "CarePlanExampleTier2"] ; # fhir:meta [ fhir:profile ( [ fhir:v "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-careplan"^^xsd:anyURI ; fhir:l ] ) ] ; # fhir:text [ fhir:status [ fhir:v "extensions" ] ; fhir:div [ fhir:v "

Narrativa gerada: CarePlan CarePlanExampleTier2

HEARTLAND Facility Implementation Tier: Tier 2 - Standard

HEARTLAND Monitoring Track Assignment: Analog Track B

status: Active

intent: Plan

subject: Rural Patient Example Female, DoB: 1947-06-15 ( https://fhir.heartlandprotocol.org/sid/example-mrn#EXAMPLE-001)

period: 2026-04-16 --> 2026-07-16

activity

Details

-StatusScheduled[x]Description
*Not StartedUma vezInitiate 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.

activity

Details

-StatusScheduled[x]Description
*ScheduledUma vezPost-discharge contact within 48 hours by RN champion.

activity

Details

-StatusDescription
*Scheduled7-day in-person follow-up visit at FQHC for vitals, medication reconciliation, and GDMT titration.

activity

Details

-StatusScheduled[x]Description
*ScheduledContagem 4 times, Uma vez por 1 weekWeekly follow-up phone calls x 4 weeks (Track B analog) capturing weight, blood pressure, oxygen saturation, and symptom assessment.

activity

Details

-StatusDescription
*ScheduledFull 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.

activity

Details

-StatusDescription
*ScheduledPatient assistance program (PAP) pursuit + Generic Bridge for medication access. Generic therapy is superior to no therapy; never delay treatment while waiting for paperwork.

note:

Tier 2 protocol: full implementation over 12 months with phased rollout. Quality metrics: dose optimization and 30-day readmission reduction.

\n
"^^rdf:XMLLiteral ] ] ; # fhir:extension ( [ fhir:url [ fhir:v "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-facility-tier"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "https://fhir.heartlandprotocol.org/CodeSystem/heartland-implementation-tier"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "tier-2-standard" ] ; fhir:display [ fhir:v "Tier 2 - Standard" ] ] ) ] ] [ fhir:url [ fhir:v "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-monitoring-track-ext"^^xsd:anyURI ; fhir:l ] ; fhir:value [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "https://fhir.heartlandprotocol.org/CodeSystem/heartland-monitoring-track"^^xsd:anyURI ; fhir:l ] ; fhir:code [ fhir:v "analog-track-b" ] ; fhir:display [ fhir:v "Analog Track B" ] ] ) ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:intent [ fhir:v "plan"] ; # fhir:subject [ fhir:l ; fhir:reference [ fhir:v "Patient/PatientExampleRural" ] ] ; # fhir:period [ fhir:start [ fhir:v "2026-04-16"^^xsd:date ] ; fhir:end [ fhir:v "2026-07-16"^^xsd:date ] ] ; # fhir:activity ( [ fhir:detail [ fhir:status [ fhir:v "not-started" ] ; fhir:scheduled [ a fhir:Timing ; fhir:repeat [ fhir:bounds [ a fhir:Period ; fhir:start [ fhir:v "2026-04-16"^^xsd:date ] ; fhir:end [ fhir:v "2026-04-30"^^xsd:date ] ] ] ] ; fhir:description [ fhir:v "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." ] ] ] [ fhir:detail [ fhir:status [ fhir:v "scheduled" ] ; fhir:scheduled [ a fhir:Timing ; fhir:repeat [ fhir:bounds [ a fhir:Period ; fhir:start [ fhir:v "2026-04-16"^^xsd:date ] ; fhir:end [ fhir:v "2026-04-18"^^xsd:date ] ] ] ] ; fhir:description [ fhir:v "Post-discharge contact within 48 hours by RN champion." ] ] ] [ fhir:detail [ fhir:status [ fhir:v "scheduled" ] ; fhir:description [ fhir:v "7-day in-person follow-up visit at FQHC for vitals, medication reconciliation, and GDMT titration." ] ] ] [ fhir:detail [ fhir:status [ fhir:v "scheduled" ] ; fhir:scheduled [ a fhir:Timing ; fhir:repeat [ fhir:count [ fhir:v "4"^^xsd:positiveInteger ] ; fhir:frequency [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:period [ fhir:v "1"^^xsd:decimal ] ; fhir:periodUnit [ fhir:v "wk" ] ] ] ; fhir:description [ fhir:v "Weekly follow-up phone calls x 4 weeks (Track B analog) capturing weight, blood pressure, oxygen saturation, and symptom assessment." ] ] ] [ fhir:detail [ fhir:status [ fhir:v "scheduled" ] ; fhir:description [ fhir:v "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." ] ] ] [ fhir:detail [ fhir:status [ fhir:v "scheduled" ] ; fhir:description [ fhir:v "Patient assistance program (PAP) pursuit + Generic Bridge for medication access. Generic therapy is superior to no therapy; never delay treatment while waiting for paperwork." ] ] ] ) ; # fhir:note ( [ fhir:text [ fhir:v "Tier 2 protocol: full implementation over 12 months with phased rollout. Quality metrics: dose optimization and 30-day readmission reduction." ] ] ) . # # -------------------------------------------------------------------------------------