Care Plans
Manage coordinated patient care plans and tasks
HF Disease Management
ActivePatricia Kowalski|Chronic Disease|Review: Apr 15, 2026
8/12 (67%)
Goals
Reduce BNP to <200 pg/mLAchieve NYHA Class IIWeight within 2 lbs dry weight
Key Interventions
Daily weight monitoringSodium restriction <2g/dayOptimize GDMT: ACEi/ARB, BB, MRA
Linked CH Axes
PONMSC
Post-TAVR Recovery
ActiveEleanor Whitfield|Procedural|Review: Apr 30, 2026
3/10 (30%)
Goals
Successful valve deploymentAmbulate 200ft by dischargeNo paravalvular leak >mild
Key Interventions
Pre-op clearance labsHeart Team conferencePost-op echo at 30 days
Linked CH Axes
POERRS
AFib Rhythm Management
ActiveDorothy Hayes|Chronic Disease|Review: Apr 10, 2026
6/8 (75%)
Goals
Maintain sinus rhythm >80%CHA2DS2-VASc managedNo stroke/TIA events
Key Interventions
Catheter ablation evaluationDOAC anticoagulationRate control backup strategy
Linked CH Axes
NMERTA
CAD Risk Optimization
ActiveJames Morrison|Prevention|Review: May 1, 2026
5/7 (71%)
Goals
LDL <70 mg/dLBP <130/80HbA1c <7%Exercise 150 min/week
Key Interventions
Statin intensificationCardiac rehab enrollmentMediterranean diet counseling
Linked CH Axes
POSCES
Cardiomyopathy Workup
ActiveRoberto Espinoza|Diagnostic|Review: Apr 20, 2026
4/9 (44%)
Goals
Determine etiology of new CMPAssess for reversible causesEstablish baseline EF
Key Interventions
Cardiac MRIGenetic panelCoronary angiographyEndomyocardial biopsy if indicated
Linked CH Axes
PONMPV
Anticoagulation Management
ActiveWilliam Jackson|Medication Management|Review: Apr 5, 2026
7/8 (88%)
Goals
INR 2.0-3.0 (or transition to DOAC)No bleeding eventsCHADS-VASc addressed
Key Interventions
Weekly INR monitoringEvaluate DOAC candidacyFall risk assessment
Linked CH Axes
NMSCRS
VT Prevention & ICD
ActiveMildred Brooks|Device Management|Review: Apr 8, 2026
5/6 (83%)
Goals
ICD implanted and functionalNo VT recurrenceAntiarrhythmic optimized
Key Interventions
ICD implantation (completed)Amiodarone loadingQuarterly device interrogation
Linked CH Axes
NMERTA
LVAD Evaluation
ActiveThomas Williams|Advanced Therapy|Review: Apr 25, 2026
2/8 (25%)
Goals
Complete LVAD candidacy workupPsychosocial readiness assessmentCaregiver training plan
Key Interventions
Right heart catheterizationDental clearanceSocial work evaluationNutrition optimization
Linked CH Axes
POESPV
Hypertension Control
ActiveKenneth Fischer|Chronic Disease|Review: Apr 12, 2026
4/6 (67%)
Goals
Office BP <130/8024-hr ABPM <125/75Rule out secondary causes
Key Interventions
Renal artery ultrasoundAldosterone:renin ratioTriple therapy optimization
Linked CH Axes
POSCNM
Post-CABG Recovery
CompletedMary Kowalczyk|Procedural|Review: Mar 15, 2026
10/10 (100%)
Goals
Sternal wound healedCardiac rehab enrolledDAPT maintained 12 months
Key Interventions
Wound care protocolCardiac rehabilitationLipid optimization
Linked CH Axes
PORSES
Lipid Optimization
On HoldEdward Kowalski|Prevention|Review: Apr 18, 2026
3/5 (60%)
Goals
LDL <55 mg/dL (FH target)Lp(a) addressedNo hepatotoxicity
Key Interventions
PCSK9 inhibitor initiationLFT monitoringCascade family screening
Linked CH Axes
POSCPV
Pulmonary HTN Workup
DraftPeter Andersen|Diagnostic|Review: May 1, 2026
0/7 (0%)
Goals
Classify PH groupRight heart cath completedTreatment initiated
Key Interventions
V/Q scanRight heart catheterizationCT pulmonary angiography
Linked CH Axes
PONMRS