Healthcare Hypertension Protocol

HEALTHCARE HYPERTENSION PROTOCOL

Clinic/Practice Name:    Protocol Effective Date:

Purpose and Scope

This Hypertension Protocol establishes standardized clinical criteria and authorized clinical actions for the identification, initiation, titration, monitoring, and referral of adults with elevated blood pressure (BP). The protocol authorizes licensed clinicians to implement evidence-based interventions within the scope of their licensure and consistent with applicable law. The patient’s signature at the end of this document constitutes informed consent to treatment under this protocol and acknowledgement of the provisions set forth below.

Patient Information

Insurance & Billing Information

Medical History & Baseline

Baseline Office BP on — Systolic: mmHg; Diastolic: mmHg.

Risk Factor Assessment

Check applicable risk factors:

Diabetes mellitus    Chronic kidney disease    Prior cardiovascular disease

Current tobacco use    Obesity    Family history of premature CVD

Target Blood Pressure & Management Plan

Authorized management actions (select all that apply). Clinicians authorized under this protocol may initiate or adjust therapies listed below when criteria are met and as clinically appropriate.

Lifestyle counseling (dietary sodium reduction, DASH, weight, activity)

Arrange home BP monitoring and instruct on proper technique

Initiate antihypertensive medication per protocol algorithm

Titrate medication dose per protocol at scheduled intervals

Refer to specialist (cardiology/nephrology) when criteria met

Urgent referral to emergency care if measured BP exceeds: or if patient has acute target-organ symptoms (chest pain, altered mentation, acute visual change, acute kidney injury).

Medication Orders (Authorized by Protocol)

Complete one or more medication order entries below as needed. Orders may be initiated or titrated per algorithm and clinical judgment.

Laboratory & Monitoring Orders

Select ordered tests and monitoring frequency:

Basic metabolic panel (BMP)    Lipid panel    Hemoglobin A1c

Urinalysis    Pregnancy test (when indicated)

Patient Education & Consent

I understand that this Hypertension Protocol describes recommended clinical actions, including lifestyle counseling, home blood pressure monitoring, laboratory monitoring, medication initiation and titration, and referral thresholds. I understand the risks and benefits of antihypertensive therapy, including but not limited to symptomatic hypotension, electrolyte changes, kidney function changes, and medication-specific adverse effects. I acknowledge that no outcome can be guaranteed.

By signing below I authorize clinicians operating under this protocol to initiate and adjust antihypertensive therapy in my care as indicated, to order laboratory tests and diagnostic studies, to communicate with my pharmacy and other healthcare providers for coordination of care, and to refer me to a specialist or emergency care if clinically necessary. I understand I may refuse or withdraw consent at any time without prejudice to future care.

I acknowledge I have received verbal and/or written education regarding hypertension management.

Date education provided:

HIPAA / Privacy Acknowledgment

I acknowledge that the clinic’s Notice of Privacy Practices describing how my protected health information may be used and disclosed has been made available to me. I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations as necessary for management under this protocol.

I acknowledge receipt of the clinic's privacy notice and consent to the uses described above.

Authorization Period & Clinician Oversight

This authorization for treatment under the Hypertension Protocol expires on: . Clinicians implementing this protocol remain subject to applicable professional standards and may deviate from the protocol when clinical judgment indicates it is necessary to ensure patient safety.

The clinic and its clinicians shall not be liable for unforeseeable adverse outcomes resulting from accepted clinical care provided under this protocol when such care is within the scope of the protocol and accepted standards. This protocol does not create a contractual guarantee of specific outcomes.

Clinician Authorizing Protocol Use (for record)

Sign Now