Hypertension

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Trace DC4-3

DiraChart Clinical Reference
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1. Where this overlay applies

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2. Plan-of-care goals — provider parameters govern

The patient-specific, provider-ordered parameters always control. Record them first; the goals that follow are completed with the patient's actual ordered values, and every threshold elsewhere in this overlay defers to these orders.

▶ Provider-ordered parameters — record before charting goals

Ordered blood-pressure range: ______ to ______.

Report thresholds: systolic above ______ or below ______; diastolic above ______ or below ______.

Heart-rate range: ______ to ______.

Sodium limit: ______ mg/day.

Home blood-pressure monitoring schedule: ______.

Antihypertensive regimen and any titration parameters: ______.

Plan-of-care goal templates

Edit each goal to the patient's ordered values and target dates.

  • Patient will maintain blood pressure within the ordered range (______ to ______), verbalizing correct home measurement technique and the report thresholds, by [date].
  • Patient and caregiver will demonstrate accurate home blood-pressure measurement with teach-back ≥ 90% by [date].
  • Patient will adhere to the antihypertensive regimen and the ordered sodium limit, verbalizing purpose and adverse effects, by [date].
  • Patient will remain free of hypertensive emergency and avoidable acute-care use through the certification period.
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