Heart Failure

At goal / managed

G1 *Stable HF on GDMT at target dry weight*	Heart-failure-specific review completed alongside the cardiovascular and respiratory examinations. Daily weight 168 lb, at the ordered target dry weight and stable over the past week; green zone. No orthopnea, paroxysmal nocturnal dyspnea, or change in exertional tolerance; volume findings unchanged from baseline (documented in the parent modules). Guideline-directed therapy tolerated without adverse effects; most recent electrolytes within parameters. Findings consistent with a managed, at-goal status on guideline-directed medical therapy. RN-level assessment was required to trend volume against the target weight and evaluate the diuretic and neurohormonal regimen. Daily-weight thresholds and the action plan reinforced; continued skilled monitoring indicated.
G2 *Post-discharge HF improving, congestion resolving*	Heart-failure-specific review completed at the post-hospitalization visit. Daily weight 174 lb, down 2 lb since the last visit and trending toward the ordered dry weight; edema improved and no S3 today (documented in the parent modules); the patient denies orthopnea or new dyspnea and reports improved exertional tolerance — green-to-yellow transition resolving toward green. The adjusted diuretic dose is tolerated. Findings reflect ongoing recovery from the recent exacerbation. RN-level assessment was required to confirm continued decongestion and evaluate tolerance of the adjusted regimen. Zones reviewed with the patient and caregiver; teach-back 100%. Continued skilled monitoring indicated.
G3 *Stable after diuretic adjustment, electrolytes monitored*	Heart-failure-specific review completed. Daily weight stable at the ordered target after a recent diuretic adjustment; no orthopnea or worsening dyspnea; the patient denies dizziness or cramping. The ordered basic metabolic panel was reviewed and potassium and renal function are within parameters. Findings indicate a stable response to the adjusted diuretic. RN-level assessment was required to confirm diuretic efficacy and screen for electrolyte imbalance and volume depletion. Daily-weight thresholds, hydration within the ordered limit, and symptoms of imbalance reinforced; continued skilled monitoring indicated.
G4 *HFpEF stable, blood pressure and volume at goal*	Heart-failure-specific review completed for a patient with heart failure with preserved ejection fraction. Blood pressure within the ordered range; daily weight at target with no abrupt change; no orthopnea or new dyspnea; volume findings at baseline (documented in the parent modules). The patient reports adherence to the sodium and fluid limits and to the regimen. Findings are at goal. RN-level assessment was required to monitor volume and blood-pressure control, which are central to managing this phenotype, and to evaluate regimen tolerance. Sodium and fluid limits, daily weights, and the action plan reinforced; continued skilled monitoring indicated.

Stable HF on GDMT at target dry weight

Heart-failure-specific review completed alongside the cardiovascular and respiratory examinations. Daily weight 168 lb, at the ordered target dry weight and stable over the past week; green zone. No orthopnea, paroxysmal nocturnal dyspnea, or change in exertional tolerance; volume findings unchanged from baseline (documented in the parent modules). Guideline-directed therapy tolerated without adverse effects; most recent electrolytes within parameters. Findings consistent with a managed, at-goal status on guideline-directed medical therapy. RN-level assessment was required to trend volume against the target weight and evaluate the diuretic and neurohormonal regimen. Daily-weight thresholds and the action plan reinforced; continued skilled monitoring indicated.

Post-discharge HF improving, congestion resolving

Heart-failure-specific review completed at the post-hospitalization visit. Daily weight 174 lb, down 2 lb since the last visit and trending toward the ordered dry weight; edema improved and no S3 today (documented in the parent modules); the patient denies orthopnea or new dyspnea and reports improved exertional tolerance — green-to-yellow transition resolving toward green. The adjusted diuretic dose is tolerated. Findings reflect ongoing recovery from the recent exacerbation. RN-level assessment was required to confirm continued decongestion and evaluate tolerance of the adjusted regimen. Zones reviewed with the patient and caregiver; teach-back 100%. Continued skilled monitoring indicated.

Stable after diuretic adjustment, electrolytes monitored

Heart-failure-specific review completed. Daily weight stable at the ordered target after a recent diuretic adjustment; no orthopnea or worsening dyspnea; the patient denies dizziness or cramping. The ordered basic metabolic panel was reviewed and potassium and renal function are within parameters. Findings indicate a stable response to the adjusted diuretic. RN-level assessment was required to confirm diuretic efficacy and screen for electrolyte imbalance and volume depletion. Daily-weight thresholds, hydration within the ordered limit, and symptoms of imbalance reinforced; continued skilled monitoring indicated.

HFpEF stable, blood pressure and volume at goal

Heart-failure-specific review completed for a patient with heart failure with preserved ejection fraction. Blood pressure within the ordered range; daily weight at target with no abrupt change; no orthopnea or new dyspnea; volume findings at baseline (documented in the parent modules). The patient reports adherence to the sodium and fluid limits and to the regimen. Findings are at goal. RN-level assessment was required to monitor volume and blood-pressure control, which are central to managing this phenotype, and to evaluate regimen tolerance. Sodium and fluid limits, daily weights, and the action plan reinforced; continued skilled monitoring indicated.

1. Where this overlay applies

At goal / managed