Healthcare HTN Protocol

HEALTHCARE HTN PROTOCOL

Clinic / Provider Name:     Patient Name:

Date of Assessment:     Medical Record No.:

Patient Information

Male    Female    Other

Insurance Information

Medical History & Current Status

Tobacco Use: Current Former Never

Vitals & Blood Pressure Measurement

Clinic BP Reading(s): Systolic mmHg    Diastolic mmHg    HR: bpm

Measurement method (check all that apply):
Automated device Manual cuff Home readings available Ambulatory BP monitoring

Technique notes:

BP Classification and Targets

Current classification (select):
Normal (< 120/80) Elevated (120–129/<80) Stage 1 (130–139/80–89) Stage 2 (≥140/90)

Individualized BP target:    Rationale/Notes:

Protocol Orders & Medication Plan

Initial therapy (select applicable classes; specify agent and dose below):
Thiazide diuretic ACE inhibitor ARB Calcium channel blocker Beta blocker

Safety monitoring required (labs / symptoms):

Urgent & Emergency Criteria

Immediate escalation criteria (check all that apply):
Chest pain, shortness of breath, neurologic deficit Signs of end-organ damage BP ≥ 180 systolic or ≥ 120 diastolic

Action for urgent readings:

Follow-up & Documentation

Follow-up schedule:

HIPAA & Treatment Authorization

I acknowledge receipt of the clinic's privacy practices and authorize the healthcare team to manage my hypertension according to this protocol, which may include medication initiation, dose adjustment, laboratory monitoring, and referrals. I understand that I may decline or withdraw consent at any time.

I acknowledge I have received and understand the privacy notice and agree to treatment under this HTN protocol.

Authorization expiration date:

Patient or Legal Representative understands the benefits, risks, and alternatives to the treatment options reviewed and may contact the clinic for any questions or to revoke this authorization.

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