Post-discharge monitoring · Heart failure

The first 30 days home, checked every morning.

When a heart-failure patient leaves the hospital, MyndfulPal checks in with them every day for 30 days: six questions, a weigh-in and a blood pressure. If the answers show a change, a nurse gets one episode to review with the evidence attached, and finishes with a note the AI drafts and the nurse signs.

Book a demo See the 30 days

For patients their clinic enrolls after a heart-failure stay. Everyone else keeps the standard daily check-in.

From discharge to day 30

From the discharge papers to a signed note

Ten steps, shared between the patient’s phone, the care-team portal and what MyndfulPal does on its own. The AI reads and drafts. A nurse checks everything it produces before it counts.

  • On the patient’s phone
  • In the care-team portal
  • AI, checked by a nurse
  • Automatic
  1. 01 · Care team

    Enroll

    The clinic adds the patient, or opens their record, and enrolls them in 30-day monitoring.

  2. 02 · Patient

    Confirm and agree

    They enter their date of birth, then agree to daily monitoring and to AI reading their papers.

  3. 03 · Patient or team

    Discharge papers

    Photos of each page or a PDF, sent from the patient’s phone or uploaded in the portal.

  4. 04 · AI

    Read

    Diagnosis, dates, discharge weight, medicine changes and follow-ups, each with its page and how sure the AI is.

  5. 05 · Care team

    Verify

    A nurse checks each field against the original. Only what they verify is used.

  6. 06 · Care team

    Activate

    Thirty days from the discharge date, with blood pressure, pulse and weight limits for this patient.

  7. 07 · Patient

    Check in

    Six questions each morning: breathing, swelling, weight, medicines, anything new, blood pressure.

  8. 08 · Automatic

    Evaluate

    The check-in is compared with earlier ones and the discharge weight. A change opens one episode.

  9. 09 · Care team

    Review

    A nurse assesses the patient, then continues monitoring, resolves the episode, or escalates.

  10. 10 · AI, then nurse

    Sign

    The AI drafts the nursing note from the facts. The nurse edits it and signs.

Setup

The discharge papers become the plan

  • Sent in about a minute. Patients photograph each page or upload the PDF from their phone. Staff can upload papers for them.
  • Read by AI, with its sources. Each field notes the page it came from and how sure the AI is, like “Handwritten: please check.” It also reads the name and date of birth on the papers, and warns the nurse if they don’t match the patient.
  • Verified by a nurse. The nurse checks every field against the original, side by side. The original is never changed, and nothing from it reaches monitoring until it’s verified.
  • No consent, no AI. If a patient hasn’t agreed to AI reading, their papers never go to it. The nurse fills in the fields from the original instead.

Then 30 days, with limits that fit the patient

Activating starts the program on the discharge date and ends it 30 days later. It needs the patient’s consent to monitoring, and it records who confirmed the limits: “Set by Jordan Lee, RN.” Any limit can be changed for one patient, and every change is logged.

LimitStarts at
Blood pressure 90–160 over 50–100
Pulse 50–110 bpm
Weight gain since the last weigh-in 2 lb, against any of the past 3 days
Weight gain in 7 days 5 lb
Weight gain from the discharge weight 5 lb, for all 30 days

The patient’s side

Six questions every morning

For 30 days, the heart-failure check-in takes the place of the usual one. Each answer saves as it’s given, and the check-in sends itself once all six are answered.

  1. 1
    Are you more short of breath than usual?
    No · A little worse · Much worse
  2. 2
    Have you noticed more swelling in your legs or feet?
    Yes · No, with how to check: press a thumb on your shin and see if it leaves a dent
  3. 3
    What is your weight today?
    In pounds. A number 5 lb away from the last one gets an “Is that right?”
  4. 4
    Did you take your medications as prescribed?
    Yes · No · Not yet
  5. 5
    Are you having dizziness, chest discomfort, or anything else different today?
    Dizziness · Chest discomfort · Something else, in their own words
  6. 6
    Did you take your blood pressure today?
    Blood pressure and heart rate now, or Remind me later for a nudge two hours on

When the 30 days end, the patient goes back to the standard check-in.

Automatic, on every check-in

One episode, not five alerts

MyndfulPal reads each check-in as a whole, next to the patient’s earlier check-ins in the program, their discharge weight and their limits. The result is at most one open episode per patient, and later check-ins update it instead of piling up. The levels come from fixed, tested rules, not from the AI.

  1. Urgent

    Chest discomfort; fainting, breathlessness at rest or coughing blood; a blood pressure in the crisis range, or a top number under 80.

    Text and email to the lead clinician and on-call staff. The patient is told to call 911.

  2. High

    Related changes together: weight with swelling or breathing, swelling with breathing, a symptom with blood pressure or pulse out of range, missed medicines with any other change, or a new change on top of the last check-in’s.

    Email to the lead clinician, and the top of Needs review.

  3. Moderate

    One change on its own, like 2.4 lb since yesterday.

    Needs review.

  4. At baseline

    Nothing new, weight steady, readings within limits.

    No episode. Monitoring continues.

  • Updates, not duplicates

    A later check-in joins the open episode. The level only goes up, and anything new or worse puts the patient back at the top of the queue.

  • The evidence stays

    Every evaluation is kept on the episode’s timeline, so the card, the escalation and the note cite what actually happened.

  • Quiet days close it

    Once a nurse has moved an episode to monitoring, three check-ins in a row at baseline close it on their own.

The care team’s side

Needs review: one queue for the nurse

Episodes and discharge papers wait in their own place in the portal, next to Triage. Most urgent first, then whoever has waited longest. Patients at their baseline aren’t listed; their monitoring just continues.

An assessment that matches the trigger

The form is built from what opened the episode: fluid and breathing questions for weight, swelling or breathlessness; blood pressure and dizziness questions for readings out of range; chest discomfort questions for the urgent pathway. The medicines question comes once, at the end. If a new kind of change arrives mid-review, its questions are added before the nurse can save.

Three ways to finish

  • Continue monitoring. The episode stays open, and the next check-ins are compared with it.
  • Resolve. The episode closes. The patient stays on 30-day monitoring.
  • Escalate. To primary care, cardiology, an NP or PA, another clinician or emergency care, with the reasons filled in from the episode and the actions taken. Follow-up notes go on the episode as answers come back.

If the patient has chest discomfort right now, or couldn’t be reached after being told to seek emergency care, not escalating needs a written reason.

Documentation

Drafted for the nurse. Signed by the nurse.

  • Written only from what’s on record: the check-in, the assessment and how it was done, any escalation and follow-ups.
  • It never adds a diagnosis, a severity, a side of the body or a plan the nurse didn’t record.
  • Every number in the draft has to appear in those facts. If one doesn’t, or the AI takes more than 20 seconds, a plain template writes the note instead.
  • Signing records the nurse’s name and the time. A signed note can’t be changed; a later assessment gets its own note.
  • Without the patient’s consent to AI, the template always writes it.

When it can’t wait

Chest discomfort skips the line

If a patient chooses chest discomfort, or types something like fainting, breathless at rest or coughing blood, the episode goes urgent the moment that answer is saved, even before the check-in is finished.

  • On the phone: a notice to call 911 if it’s happening now.
  • In the portal: the patient jumps to the top of Needs review.
  • Off the portal: a text and an email to the lead clinician and on-call staff. They say only that a check-in needs urgent review, with a link.
  • Until someone acts: with no nursing action after 15 minutes, it goes out again, up to once an hour. If nobody can be texted, the clinic’s admins are told, and the episode says so.

If what a patient types suggests they might harm themselves, they’re shown the 988 Lifeline and the care team gets the usual safety alert.

Enrollment

Before the app shows anything, a new patient enters their date of birth, and it has to match the clinic’s record. After five wrong tries the invitation locks until the clinic resends it.

Then they read and accept two agreements: one for the 30 days of monitoring, one for the AI reading their papers and drafting their nurse’s notes. Each acceptance is stored with the exact wording they saw. Patients who would rather talk it through can agree by phone; staff read them the same words and record it.

Monitoring can’t be activated without the first agreement. Without the second, nothing of theirs goes to the AI.

Walk through Mary’s day 5 in a demo

Our demo clinic has heart-failure patients already in their 30 days. Verify a discharge summary, work the queue, assess, escalate and sign a note.

Book a demo