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
<CarePlan xmlns="http://hl7.org/fhir">
<id value="CarePlanExampleTier2"/>
<meta>
<profile
value="https://fhir.heartlandprotocol.org/StructureDefinition/heartland-careplan"/>
</meta>
<text>
<status value="extensions"/>
<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>
</div></blockquote></div>
</text>
<extension
url="https://fhir.heartlandprotocol.org/StructureDefinition/heartland-facility-tier">
<valueCodeableConcept>
<coding>
<system
value="https://fhir.heartlandprotocol.org/CodeSystem/heartland-implementation-tier"/>
<code value="tier-2-standard"/>
<display value="Tier 2 - Standard"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="https://fhir.heartlandprotocol.org/StructureDefinition/heartland-monitoring-track-ext">
<valueCodeableConcept>
<coding>
<system
value="https://fhir.heartlandprotocol.org/CodeSystem/heartland-monitoring-track"/>
<code value="analog-track-b"/>
<display value="Analog Track B"/>
</coding>
</valueCodeableConcept>
</extension>
<status value="active"/>
<intent value="plan"/>
<subject>🔗
<reference value="Patient/PatientExampleRural"/>
</subject>
<period>
<start value="2026-04-16"/>
<end value="2026-07-16"/>
</period>
<activity>
<detail>
<status value="not-started"/>
<scheduledTiming>
<repeat>
<boundsPeriod>
<start value="2026-04-16"/>
<end value="2026-04-30"/>
</boundsPeriod>
</repeat>
</scheduledTiming>
<description
value="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>
</activity>
<activity>
<detail>
<status value="scheduled"/>
<scheduledTiming>
<repeat>
<boundsPeriod>
<start value="2026-04-16"/>
<end value="2026-04-18"/>
</boundsPeriod>
</repeat>
</scheduledTiming>
<description
value="Post-discharge contact within 48 hours by RN champion."/>
</detail>
</activity>
<activity>
<detail>
<status value="scheduled"/>
<description
value="7-day in-person follow-up visit at FQHC for vitals, medication reconciliation, and GDMT titration."/>
</detail>
</activity>
<activity>
<detail>
<status value="scheduled"/>
<scheduledTiming>
<repeat>
<count value="4"/>
<frequency value="1"/>
<period value="1"/>
<periodUnit value="wk"/>
</repeat>
</scheduledTiming>
<description
value="Weekly follow-up phone calls x 4 weeks (Track B analog) capturing weight, blood pressure, oxygen saturation, and symptom assessment."/>
</detail>
</activity>
<activity>
<detail>
<status value="scheduled"/>
<description
value="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>
</activity>
<activity>
<detail>
<status value="scheduled"/>
<description
value="Patient assistance program (PAP) pursuit + Generic Bridge for medication access. Generic therapy is superior to no therapy; never delay treatment while waiting for paperwork."/>
</detail>
</activity>
<note>
<text
value="Tier 2 protocol: full implementation over 12 months with phased rollout. Quality metrics: dose optimization and 30-day readmission reduction."/>
</note>
</CarePlan>