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Heart Failure Care Plans

Graphnet's Shared Care heart failure care plans help care teams assess, monitor and manage patients living with heart failure.

About the Heart Failure Care Plan

The Heart Failure Care Plan is a condition-specific care planning and assessment form which supports care teams to assess, monitor and manage patients living with Heart Failure. Used in conjunction with Graphnet Shared Care, the solution provides a holistic view of a person’s specific, as well as general care, well-being and support needs. Clinicians can view data entered directly into​ Graphnet's Personal Health Record (PHR), whilst patients are able to view their care plan within the PHR app, all displayed in real time.

In addition to this, data can be manually added to the care plan as part of a consultation, maintaining a full record of the person's condition​. Specific heart failure medication can be recommended within the plan for either prescribing or to discontinue (note, this is not a prescription). The primary care team can review these recommendations and update the status accordingly.​


  • Accurate, real-time information in one, accessible place: Contributed to by all those involved in the patient’s care as it sits within the shared care record, the heart failure care plan provides real time availability of up to date information, such as current (and discontinued) heart failure medications. This is available for others to view including Out of Hours and Emergency Care.
  • Time savings: Authorised users can quickly and easily record heart failure history, medication, observation and results information, as well as ongoing progress and management plans from one place which reduces chasing of information from different care providers.
  • Care that's tailored to the individual: A fuller picture of the individual enables care teams to adapt treatment where required.


The solution offers the ability to record:

  • ‘My heart failure’ details on behalf of the patient.
  • Specific heart failure medication details, with quick access views of GP contributed medication information.
  • Relevant findings and results details over a full course of assessments.
  • Details of patient progress and clinical management plans over the full care journey.
  • Create an Integrated Care & Support Plan (including ‘about you’ details, goal tracking and contingency planning) and End of Life(EPaCCS) record, if applicable.
  • Enter key care contacts (both personal and professional).
  • Record MDT meeting actions and outcomes.
  • Upload images of relevant, supporting care planning documents, such as ReSPECT forms.
  • These add to existing multi-disciplinary functionality such as End of Life and Multi-Disciplinary Team (MDT) referral & meeting recording / reporting solution.