HEARTLAND Protocol FHIR Implementation Guide
0.3.0 -
HEARTLAND Protocol FHIR Implementation Guide
0.3.0 -
HEARTLAND FHIR candidate 0.3.0 — draft, experimental R4 4.0.1 reference. Prepared for technical review; not evidence of clinical validation or vendor interoperability.
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<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: 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">Profile: <a href="StructureDefinition-heartland-careplan.html">HEARTLAND Care Plan</a></p></div><p><b>HEARTLAND Facility Implementation Tier</b>: <span title="Codes:{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="Codes:{https://fhir.heartlandprotocol.org/CodeSystem/heartland-monitoring-track analog-track-b}">Analog Track B</span></p><p><b>status</b>: Draft</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><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>Not Started</td><td>Medication planning: an authorized professional reviews indications, tolerability, laboratory evidence, access and the individual plan. Facility tier does not prescribe a drug sequence or a universal initiation deadline. No medication order is represented here.</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>Not Started</td><td>Follow-up planning: document the risk-led timing, responsible professional, named backup, supported route and escalation for unavailable coverage. No appointment, contact or response-time guarantee is asserted.</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>Not Started</td><td>Monitoring planning: confirm telephone access and patient preference for the illustrative Track B route; document an alternative and unresolved access gap when necessary. A paper diary or attempted call does not establish review.</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>Not Started</td><td>Examination follow-up planning: retain request, access, actual collection, result version, professional review, decision, communication and closure evidence as distinct records. This plan does not transmit an order or attest that any stage occurred.</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>Not Started</td><td>Referral planning: identify the need, destination and accountable professional, then record acceptance, attendance, report, review and communication separately. An offered transfer is not accepted responsibility or a completed consultation.</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>Not Started</td><td>Medication-access planning: document barriers, assistance options and the prescriber's individualized plan. Assistance application or approval is not medication obtained, adherence or therapeutic equivalence.</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>Not Started</td><td>Education — Daily Weight: plan teaching and professional teach-back about the patient's written monitoring and contact instructions; do not infer completion from an entry.</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>Not Started</td><td>Education — Medications: plan teaching and professional teach-back about the individualized medication plan and barriers; no dose or therapy change is ordered by this example.</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>Not Started</td><td>Education — Warning Signs: plan teaching and professional teach-back about the written warning-sign and emergency instructions; a displayed message does not establish understanding.</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>Not Started</td><td>Education — Understanding Heart Failure: offer an explanation suited to the patient's language and needs, with professional teach-back recorded separately.</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>Not Started</td><td>Education — Sodium: use the individual's documented dietary guidance; this example does not impose a universal numerical restriction.</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>Not Started</td><td>Education — Fluids: explain fluid-related symptoms and the individual's written guidance; a fluid restriction is not assumed for every patient.</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>Not Started</td><td>Education — When to Call: plan teaching and professional teach-back about the written contact and emergency routes, including coverage gaps and supported alternatives.</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>Not Started</td><td>Education — Activity Guidance: discuss the individual's activity plan and limitations; no universal exercise prescription or completed instruction is asserted.</td></tr></table></blockquote><p><b>note</b>: , </p><blockquote><div><p>Offer all eight domains at every tier; tier can change format, sequence and support, not exclude a clinically relevant domain. Patient self-assessment is not professional teach-back. Domain states pending, completed, deferred and not applicable belong to separate education records; deferred or not applicable requires a written reason and named authorized decision-maker. The denominator is the applicable domain set. No education state is inferred from these not-started planned activities.</p>
</div></blockquote><blockquote><div><p>Synthetic educational implementation-support example only. No named professional, clinical approval, care delivery, validated safe waiting interval, clinical outcome or operational export is claimed. Preserve historical example versions rather than rewriting records previously exchanged.</p>
</div></blockquote></div>
</text>
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<subject>🔗
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<status value="not-started"/>
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value="Medication planning: an authorized professional reviews indications, tolerability, laboratory evidence, access and the individual plan. Facility tier does not prescribe a drug sequence or a universal initiation deadline. No medication order is represented here."/>
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<activity>
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<status value="not-started"/>
<description
value="Follow-up planning: document the risk-led timing, responsible professional, named backup, supported route and escalation for unavailable coverage. No appointment, contact or response-time guarantee is asserted."/>
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<status value="not-started"/>
<description
value="Monitoring planning: confirm telephone access and patient preference for the illustrative Track B route; document an alternative and unresolved access gap when necessary. A paper diary or attempted call does not establish review."/>
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<activity>
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<status value="not-started"/>
<description
value="Examination follow-up planning: retain request, access, actual collection, result version, professional review, decision, communication and closure evidence as distinct records. This plan does not transmit an order or attest that any stage occurred."/>
</detail>
</activity>
<activity>
<detail>
<status value="not-started"/>
<description
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<status value="not-started"/>
<description
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</detail>
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<activity>
<detail>
<status value="not-started"/>
<description
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</detail>
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<detail>
<status value="not-started"/>
<description
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</detail>
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<activity>
<detail>
<status value="not-started"/>
<description
value="Education — Warning Signs: plan teaching and professional teach-back about the written warning-sign and emergency instructions; a displayed message does not establish understanding."/>
</detail>
</activity>
<activity>
<detail>
<status value="not-started"/>
<description
value="Education — Understanding Heart Failure: offer an explanation suited to the patient's language and needs, with professional teach-back recorded separately."/>
</detail>
</activity>
<activity>
<detail>
<status value="not-started"/>
<description
value="Education — Sodium: use the individual's documented dietary guidance; this example does not impose a universal numerical restriction."/>
</detail>
</activity>
<activity>
<detail>
<status value="not-started"/>
<description
value="Education — Fluids: explain fluid-related symptoms and the individual's written guidance; a fluid restriction is not assumed for every patient."/>
</detail>
</activity>
<activity>
<detail>
<status value="not-started"/>
<description
value="Education — When to Call: plan teaching and professional teach-back about the written contact and emergency routes, including coverage gaps and supported alternatives."/>
</detail>
</activity>
<activity>
<detail>
<status value="not-started"/>
<description
value="Education — Activity Guidance: discuss the individual's activity plan and limitations; no universal exercise prescription or completed instruction is asserted."/>
</detail>
</activity>
<note>
<text
value="Offer all eight domains at every tier; tier can change format, sequence and support, not exclude a clinically relevant domain. Patient self-assessment is not professional teach-back. Domain states pending, completed, deferred and not applicable belong to separate education records; deferred or not applicable requires a written reason and named authorized decision-maker. The denominator is the applicable domain set. No education state is inferred from these not-started planned activities."/>
</note>
<note>
<text
value="Synthetic educational implementation-support example only. No named professional, clinical approval, care delivery, validated safe waiting interval, clinical outcome or operational export is claimed. Preserve historical example versions rather than rewriting records previously exchanged."/>
</note>
</CarePlan>