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
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - 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 <https://fhir.heartlandprotocol.org/StructureDefinition/heartland-careplan> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div [ fhir:v "<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>"^^rdf:XMLLiteral ]
] ; #
fhir:extension ( [
fhir:url [
fhir:v "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-facility-tier"^^xsd:anyURI ;
fhir:l <https://fhir.heartlandprotocol.org/StructureDefinition/heartland-facility-tier> ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [
fhir:v "https://fhir.heartlandprotocol.org/CodeSystem/heartland-implementation-tier"^^xsd:anyURI ;
fhir:l <https://fhir.heartlandprotocol.org/CodeSystem/heartland-implementation-tier> ] ;
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 <https://fhir.heartlandprotocol.org/StructureDefinition/heartland-monitoring-track-ext> ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [
fhir:v "https://fhir.heartlandprotocol.org/CodeSystem/heartland-monitoring-track"^^xsd:anyURI ;
fhir:l <https://fhir.heartlandprotocol.org/CodeSystem/heartland-monitoring-track> ] ;
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:Patient/PatientExampleRural ;
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." ]
] ) . #
IG © 2026+ Vicky Muller Ferreira, MD. Package heartland.fhir.us.protocol#0.1.0 based on FHIR 4.0.1. Generated 2026-04-16
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