---
title: "Heart Failure Smart Goals"
canonical: "https://wiki.patientsknowbest.com/space/DEPLOY/3572924527/Heart%20Failure%20Smart%20Goals"
format: markdown
---
> Macro (toc)

This page provides examples of SMART goals written by teams using PKB with their Heart Failure (HF) patients.

# Patient Pathway

1. HF Nurse calls the patient, explains HF diagnosis, checks PKB to see if they are registered, if not collects email and adds to webv/PKB. Explains PKB Pathway and next steps. (Send pre-questionnaire-or tell patient to complete? send a plan or ask a patient to start it?? TBC)
2. 1st Appointment is in PKB ready for patients to view.
3. Patient registers and is told to access the library for information on the pathway.
4. Patient completes a pre health questionnaire and starts a care plan.
5. Nurse reviews care plan before/at first F2F appointment, adds to the plan. Books next appointment for 2 weeks’ time (if symptom tracking currently under threshold its virtual if over its F2F)
6. Patient receives notification plan has been updated and the next appointment details in PKB.
7. Patient continues to monitor symptoms via the care plan before the next appointment.
8. Nurse reviews care plan before/on appointment, continues uptitration. Books next appointment for 2 weeks’ time (if currently under threshold its virtual if over its F2F)
9. Patient continues to monitor symptoms via the care plan before the next appointment.

10. Nurse repeats the process until the patient is on max titration, then books an ECHO for the patient.

11. Echo appointments are in PKB for patients to view.

12. Patient attends ECHO

13. Nurse discharges the patient from this pathway and sends a post health questionnaire.

![image](media://5a5b3a0f-b81c-4ca6-b770-2fc814413fcc)

# SMART GOAL Examples

## Goal 1

## Goal 2

## Goal 3

## Goal 5


Time-Bound:

To reduce 50% of DNAs within 9 months. DNA stats to be reviewed every 3 months by the team manager.

# Heart failure team - self-monitoring pathway

![image](media://febcef5a-1063-4880-9b2a-3f84dcfda6fe)

## Goal 1