RB
Bernstein, Ruth M.
Code statusDNR/DNI
AllergiesPenicillins, Sulfa
PrecautionsStandard
Last seen by me11 July
ConsentAPCM 03/12/26
Everything the record already knows
from PCCAyala's rule for this rail: bring every diagnosis in, then filter. Relevant means still being treated, or anything at all within the last 30 days. The catch: PCC has no active/resolved flag — it is an append-and-strike list with a rank, a classification and one date. Relevance has to be derived, and that derivation is a feature nobody owns yet.
Monthly APCM review — August 2026
31 of 34 fields pre-filledThe month's recordAssembledPCC + RPM + CoCM
Reviewed the record for the period 1–31 August 2026. Resident remains a long-term-care resident at Ashbrook, North 2, room 204A. Care continues under the primary care team with nephrology and podiatry following.
Cross-program feeds. RPM: 49 of 53 expected readings captured; 3 alerts raised, all resolved at the facility. CoCM: not enrolled. Summarised form only — raw feeds are excluded by the CCO's constraint.
Chronic conditions: 7QMB: noTier: G0557Care plan reviewed 03/12/26
Medication review — changes since last monthInferredNo feature row
| Medication | Change | Date | Detail |
|---|---|---|---|
| Metoprolol tartrate | Dose change | 07/29 | 25 mg BID → 50 mg BID |
| Furosemide | New | 08/02 | 20 mg daily, AM |
| Ciprofloxacin | Completed | 07/24 | 10-day course finished |
| Quetiapine | Discontinued | 07/31 | Gradual dose reduction — F758 |
Six clicks, gone. Today this means opening display filters, unchecking everything but pharmacy, unchecking every order status but completed and discontinued, sorting by end date descending, and reading the two lists against each other. There is no "dose changed" event in PCC — a dose change is the old dose in the discontinued list plus a new active order at the new dose, matched on drug name. That inference is ours to build, and it must not render the same drug as two concurrent prescriptions.
Why did metoprolol change? assembled
The change
25 mg BID discontinued 07/29 09:14. New order 50 mg BID same day, Dr. P. Britel, indication hypertension.
Related vitals in the window
07/26 158/94 HR 96
07/27 162/98 HR 101
07/30 138/84 HR 82
08/01 132/80 HR 78
07/27 162/98 HR 101
07/30 138/84 HR 82
08/01 132/80 HR 78
Nursing notes in the window
07/27 "BP elevated on recheck ×2, resident reports headache. MD notified."
07/31 "BP improved, asymptomatic."
07/31 "BP improved, asymptomatic."
At first release this is a prompt, not a bundle. The system spots the dose change and tells the provider where to look — "metoprolol changed 07/29; check vitals and nursing notes for that week." Ayala named both versions in that order, and the prompt is the one that ships.
To ask Ayala: what is the right window — 30 days, or since the last APCM review? And which nursing notes count: everything in the window, or only notes mentioning the drug, the vital or the symptom?
HPIProvider types thisDrafting is R&D
Type the interval history. Pre-fill covers the record, not the prose — a drafted-for-signature narrative arrives through the R&D exit gate and is never promised at first release.
Assessment & planProvider types thisConditions pre-loaded as toggles
Only the conditions addressed this month get assessed. Toggled from the evidence rail.
Heart failureHypertensionCKD stage 3Type 2 diabetesMDD, recurrent
Assessment per addressed condition, and the plan.
Chart typeDetermined
The NP performs the initiating visit. This session yields the E/M chart and the APCM enrolment together, correctly typed — the template carries everything E&M and APCM require at this moment, which is the death of the cheat sheet.
E/M initialAPCM enrolmentConsent captured 03/12/26
Medication reconciliation vs hospital dischargeHard integration dependency
Hospital discharge list
| Lisinopril 20 mg daily | Continue |
| Metoprolol 25 mg BID | Continue |
| Warfarin 5 mg daily | Discontinue |
| Apixaban 5 mg BID | Add |
Current facility list
| Lisinopril 20 mg daily | Match |
| Metoprolol 25 mg BID | Match |
| Warfarin 5 mg daily | Still active — discrepancy |
| Apixaban — absent | Missing |
Two anticoagulants, one of them missing, on an 84-year-old. That is the reconciliation this visit exists to catch, and today it is done by eye against a PDF. The dependency: the discharge document sits in PCC's Misc tab as a scanned upload. FHIR does expose
DocumentReference for read and search, so "you cannot pull documents" is not literally true — but Binary is not in the supported resource list, the only documented type is the CCD, and every document-adjacent PCC partner is push-only. This is a thirty-minute sandbox test, not an architecture decision.If the document cannot be pulled, the fallback is upload-and-parse at the initial visit — which is what RoundSmarter does. One upload per admission, not per visit.
To ask Ayala: is a one-time upload per admission acceptable, or does that reintroduce exactly the manual step we are killing?
Note on the sheet: CMS lists medication reconciliation inside APCM service element 4, comprehensive care management. No feature row on the sheet owns it. That is a gap on a Must-rated obligation.
Comprehensive assessmentPartly pre-filledBedside items typed
Functional, psychosocial and medical needs assessment. MDS-sourced signals present: BIMS 11, from the MDS feed.
Language: EnglishInterpreter needed: noAccess-to-care barriers: none recorded
Amanda's point, and it is an APCM requirement not a nicety. Language and interpreter need are part of the comprehensive assessment and a social determinant of health — "the evidence shows they get substandard care because they don't understand… this is the exact patient population the government wants you to focus on." It belongs here, on the initial visit, and it should carry forward.
Physical assessment — the part only the provider can supply.
EncounterDetermined
Follow-up E/M, in person. Date of service derives from facility-local time, and the Medicare midnight rule runs on facility midnight — both are storage-and-rendering laws, not display choices.
Date of service: 10 Aug 2026Ashbrook · facility timeSign within 24–48h
Interval since last visitAssembled
Since 11 July: 2 falls (07/18, 08/04), 1 ED visit — none. Weight −4 lb over 30 days. New order: furosemide 20 mg daily 08/02. Dose change: metoprolol 25→50 mg BID 07/29.
This section is the reason the follow-up is not just a shorter APCM. What changed since the provider was last physically here is a different question from what changed this calendar month, and only one of them is anchored to the visit.
Physical assessmentProvider types this
The examination. At first release, typed in whatever form the provider wants, shorthand included — voice capture is deliberately R&D and is not promised here.
E/M levelFlat code continues at MVP
The honest state. The APCM tier computes from the full chronic list plus QMB status. Engine E/M levelling is explicitly out of the first release — the flat E&M code continues until that engine ships. Anything that implies otherwise on this screen would be over-promising.
Judgment made explicit — the graduation ledger
The ruling, implementedAyala's model is the baseline: retrieve everything, present it, let the provider confirm. Amanda's is the target: catch the things an attentive clinician catches. The bridge is this ledger. Every observation that lives only in an experienced NP's head is a candidate to become a firing rule — and when it fires reliably, it stops being something anyone has to remember. Each card below is one of Amanda's examples, converted.
ShippedImmunisation gap
Ayala already asked for this one. Match the immunisation record against the guideline set and surface what is missing as a recommendation.
immunisations ∖ guideline_due → care gap
NextThe missing dentures
Amanda's example. A resident losing weight with no dental order and no dentures documented is a nutrition problem hiding as a weight problem.
weight_loss ≥ 5% / 30d
AND no active dental order
→ prompt: dentition assessed?
AND no active dental order
→ prompt: dentition assessed?
NextThe fall environment
A fall in the last 30 days should put the room itself on the assessment — bedrails, clutter, distance to the bathroom, glasses within reach.
fall_event within 30d
→ environment checklist on visit
→ environment checklist on visit
NextThe diet order tells you something
Ayala's insight. A chopped-texture diet implies a failed swallow evaluation; a daily weight usually means CHF. Read the order for what it implies.
diet = texture-modified
AND no dysphagia dx
→ prompt: swallow status?
AND no dysphagia dx
→ prompt: swallow status?
LaterGlasses and hearing aids
Lost in the hospital transfer, and a documented delirium aggravator. Needs a sensory-aid field that does not exist in the record today.
requires new structured field
LaterWhy did it change, assembled
The dose-change bundle above. Prompt at first release; the assembled version — vitals window plus matching nursing notes — is the one that saves the twenty minutes.
needs nursing-note retrieval + relevance ranking
To ask both of them, together if possible: this ledger is the answer to Amanda's "what you're describing is literally every other product out there." Is it the right answer? And what belongs on it that neither of you has said out loud yet?
Before this can be signed
Real-timeConsent on file, basis recorded
Initial visit completed 03/12/26
Chronic conditions captured — 7
Medication review complete
HPI is empty
Assessment is empty
2 care gaps unaddressed
Cannot be resolved with a required field empty.
Careful here — this is the card most likely to over-promise. The engine-side audit that runs during charting is real and Must-covered. But a hard gate that refuses to close a chart on a missing required field is described by no source we have. It is Sarah's ask, drawn here as a proposal.
Billing
ComputedG0557
APCM Level 2 — 2+ chronic conditions
7 captured · QMB no
7 captured · QMB no
·Tier from the full chronic list plus QMB status
·One APCM claim per calendar month, no time threshold
·Month-end lock runs on facility time
Codes: G0556 level 1 (0–1 chronic) · G0557 level 2 (2+) · G0558 level 3 (QMB with 2+). CY2026 added BHI add-ons G0568–G0570.
Care gaps found
2 open⚑RSV vaccine — eligible, never offered
⚑Shingles dose 2 — dose 1 given 03/2024
·Weight −4 lb / 30 d — under the 5% threshold, not flagged
A gap becomes a recommendation, and a recommendation travels to the DON. At first release capture happens here and delivery stays today's email-and-review process — there is no second list to keep.