Clinical documentation and the chart

C0610Does AuroraMed present a patient header/banner with identifiers, age, sex, allergies, code status, isolation and restricted flags on every chart screen?

The clinical documentation and the chart part of the specification (REQ-0401) says the system must present a patient header/banner with identifiers, age, sex, allergies, code status, isolation and restricted flags on every chart screen. The pilot covers part of this. The rest is designed, not built. Pilot detail: Basic MVP equivalent: patient banner/summary, vitals/note/I&O entries, stay/day/hour timeline, care assignment, results view; free-text, not coded or templated. Acceptance check: banner is visible on all clinical screens and print outputs.

C0611Does AuroraMed provide a chart summary/snapshot with problems, meds, allergies, vitals, recent results and care team?

How would it be tested? The specification says summary loads within the interactive budget (file 07). That is the check for REQ-0402: the system must provide a chart summary/snapshot with problems, meds, allergies, vitals, recent results and care team. The pilot covers part of this. The rest is designed, not built. Where the code stands: Basic MVP equivalent: patient banner/summary, vitals/note/I&O entries, stay/day/hour timeline, care assignment, results view; free-text, not coded or templated.

C0612Does AuroraMed manage the problem list (active/resolved/inactive) with SNOMED CT or ICD-10-CM/CIE-10 coding and verification status?

Not built. What the pilot has is a stand-in, not the feature. In the pilot: Free-text dx / allergies fields on the patient row; no coded lists, statuses or reaction/severity. For reference, REQ-0403 (a top-priority requirement, all three tiers) says the system must manage the problem list (active/resolved/inactive) with SNOMED CT or ICD-10-CM/CIE-10 coding and verification status. Check: resolving a problem requires abatement date; coded value validates against the pinned release.

C0613Does AuroraMed record medical, surgical, family and social history with coded and free-text entries?

The system must record medical, surgical, family and social history with coded and free-text entries. That is REQ-0404, a top-priority requirement for all three tiers. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Test in the specification: family history relationship uses RoleCode; social history supports SDOH codes.

C0614Does AuroraMed manage allergy/intolerance lists with reaction, severity, criticality and explicit no-known-allergies assertion?

Not built. What the pilot has is a stand-in, not the feature. Pilot detail: Free-text dx / allergies fields on the patient row; no coded lists, statuses or reaction/severity. REQ-0405 says the system must manage allergy/intolerance lists with reaction, severity, criticality and explicit no-known-allergies assertion. Its acceptance check: empty list is not treated as NKA; cross-sensitivity check fires on new orders.

C0615Does AuroraMed record vital signs and flowsheets with LOINC-mapped rows and UCUM units?

REQ-0406 is a top-priority requirement for all three tiers: the system must record vital signs and flowsheets with LOINC-mapped rows and UCUM units. The pilot covers part of this. The rest is designed, not built. Where the code stands: Basic MVP equivalent: patient banner/summary, vitals/note/I&O entries, stay/day/hour timeline, care assignment, results view; free-text, not coded or templated. To verify it, the specification says unit conversion preserves both original and normalized values.

C0616Does AuroraMed support clinical notes of all types in file 01 with structured sections and free text?

The clinical documentation and the chart part of the specification (REQ-0407) says the system must support clinical notes of all types in file 01 with structured sections and free text. The pilot covers part of this. The rest is designed, not built. In the pilot: Basic MVP equivalent: patient banner/summary, vitals/note/I&O entries, stay/day/hour timeline, care assignment, results view; free-text, not coded or templated. Acceptance check: each note type has a registry definition; unknown note type rejected.

C0617Does AuroraMed provide templates, smart phrases and macros with variable substitution that cannot execute code?

How would it be tested? The specification says attempt to embed script is refused. That is the check for REQ-0408: the system must provide templates, smart phrases and macros with variable substitution that cannot execute code. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet.

C0618Does AuroraMed support voice dictation with review before filing; audio is not retained beyond policy?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. For reference, REQ-0409 (a medium-priority requirement, all three tiers) says the system must support voice dictation with review before filing; audio is not retained beyond policy. Check: dictated text is filed only after user acceptance.

C0619Does AuroraMed optionally support ambient AI documentation as draft notes under section AI?

The system must optionally support ambient AI documentation as draft notes under section AI. That is REQ-0410, a lower-priority requirement for the medium and large tiers. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Test in the specification: draft is labeled AI and cannot be filed without signature.

C0620Does AuroraMed support copy-forward with visible change highlighting and provenance?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. REQ-0411 says the system must support copy-forward with visible change highlighting and provenance. Its acceptance check: copied text shows original source and date.

C0621Does AuroraMed support note signing, cosigning, attestation and teaching-physician statements?

REQ-0412 is a top-priority requirement for all three tiers: the system must support note signing, cosigning, attestation and teaching-physician statements. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. To verify it, the specification says trainee note remains pending until attending attestation when policy requires.

C0622Does AuroraMed support addenda, amendments and entered-in-error marking without deleting original content?

The clinical documentation and the chart part of the specification (REQ-0413) says the system must support addenda, amendments and entered-in-error marking without deleting original content. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Acceptance check: original text remains retrievable by HIM with audit.

C0623Does AuroraMed support late entries with both event time and entry time displayed?

How would it be tested? The specification says late entry banner shown. That is the check for REQ-0414: the system must support late entries with both event time and entry time displayed. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet.

C0624Does AuroraMed capture structured data through discrete forms and questionnaires (FHIR Questionnaire/SDC)?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. For reference, REQ-0415 (a top-priority requirement, all three tiers) says the system must capture structured data through discrete forms and questionnaires (FHIR Questionnaire/SDC). Check: form response validates against form version.

C0625Does AuroraMed provide document management: scanning, indexing, OCR, categories, encounter links and fax intake?

The system must provide document management: scanning, indexing, OCR, categories, encounter links and fax intake. That is REQ-0416, a top-priority requirement for all three tiers. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Test in the specification: scanned document is virus/CDR scanned and indexed before filing.

C0626Does AuroraMed capture clinical photographs and wound images with annotation, measurement scale and consent?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. REQ-0417 says the system must capture clinical photographs and wound images with annotation, measurement scale and consent. Its acceptance check: image stored with EXIF removed and consent flag.

C0627Does AuroraMed provide body diagrams with vector annotations?

REQ-0418 is a medium-priority requirement for the medium and large tiers: the system must provide body diagrams with vector annotations. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. To verify it, the specification says marks remain vector data.

C0628Does AuroraMed provide validated clinical calculators with versioned formulas?

The clinical documentation and the chart part of the specification (REQ-0419) says the system must provide validated clinical calculators with versioned formulas. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Acceptance check: formula version is recorded with result.

C0629Does AuroraMed provide a clinical inbox with pooled and delegated queues for results, messages, refill requests and referrals; every item has an owner?

How would it be tested? The specification says unowned items escalate after the configured interval. That is the check for REQ-0420: the system must provide a clinical inbox with pooled and delegated queues for results, messages, refill requests and referrals; every item has an owner. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet.

C0630Does AuroraMed generate result-notification letters and templates?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. For reference, REQ-0421 (a high-priority requirement, all three tiers) says the system must generate result-notification letters and templates. Check: letter uses patient language and release rules.

C0631Does AuroraMed support letters, forms and correspondence templates and FMLA/disability forms?

The system must support letters, forms and correspondence templates and FMLA/disability forms. That is REQ-0422, a high-priority requirement for all three tiers. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Test in the specification: template variables fill from chart.

C0632Does AuroraMed generate and consume C-CDA documents and represent notes as FHIR DocumentReference/Composition?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. REQ-0423 says the system must generate and consume C-CDA documents and represent notes as FHIR DocumentReference/Composition. Its acceptance check: c-CDA passes scorecard validation.

C0633Does AuroraMed support Open Notes / Cures Act sharing with exceptions and documented reasons?

REQ-0424 is a top-priority requirement for all three tiers: the system must support Open Notes / Cures Act sharing with exceptions and documented reasons. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. To verify it, the specification says blocked note shows exception code to privacy staff.

C0634Does AuroraMed segment psychotherapy notes and 42 CFR Part 2 records into separate compartments?

The clinical documentation and the chart part of the specification (REQ-0425) says the system must segment psychotherapy notes and 42 CFR Part 2 records into separate compartments. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Acceptance check: standard chart views omit them; access needs purpose.

C0635Does AuroraMed document interpreter use?

How would it be tested? The specification says interpreter fields required when flag is set. That is the check for REQ-0426: the system must document interpreter use. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet.

C0636Does AuroraMed support clinical coding of encounters (ICD-10-CM, CPT/HCPCS, CIE-10 and country equivalents) with encoder integration?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. For reference, REQ-0427 (a top-priority requirement, all three tiers) says the system must support clinical coding of encounters (ICD-10-CM, CPT/HCPCS, CIE-10 and country equivalents) with encoder integration. Check: coded claim validates before release.

C0637Does AuroraMed provide a longitudinal timeline view across encounters and external sources?

The system must provide a longitudinal timeline view across encounters and external sources. That is REQ-0428, a high-priority requirement for the medium and large tiers. The pilot covers part of this. The rest is designed, not built. What v0.2.0 does today: Basic MVP equivalent: patient banner/summary, vitals/note/I&O entries, stay/day/hour timeline, care assignment, results view; free-text, not coded or templated. Test in the specification: external items are visually distinct.

C0638Does AuroraMed support external/outside record reconciliation and incorporation?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. REQ-0429 says the system must support external/outside record reconciliation and incorporation. Its acceptance check: reconciliation never overwrites local data without user acceptance.

C0639Does AuroraMed provide assessments and scores (pain, falls, pressure injury, nutrition) with versioned instruments?

REQ-0430 is a top-priority requirement for all three tiers: the system must provide assessments and scores (pain, falls, pressure injury, nutrition) with versioned instruments. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. To verify it, the specification says score range checks pass.

C0640Does AuroraMed provide care team management and patient-provider relationships that drive access policy?

The clinical documentation and the chart part of the specification (REQ-0431) says the system must provide care team management and patient-provider relationships that drive access policy. The pilot covers part of this. The rest is designed, not built. In the pilot: Basic MVP equivalent: patient banner/summary, vitals/note/I&O entries, stay/day/hour timeline, care assignment, results view; free-text, not coded or templated. Acceptance check: care-team change updates access within seconds.

C0641Does AuroraMed provide patient lists with minimum-necessary query enforcement?

How would it be tested? The specification says lists exceeding role limits are truncated and audited. That is the check for REQ-0432: the system must provide patient lists with minimum-necessary query enforcement. The pilot covers part of this. The rest is designed, not built. What v0.2.0 does today: Basic MVP equivalent: patient banner/summary, vitals/note/I&O entries, stay/day/hour timeline, care assignment, results view; free-text, not coded or templated.

C0642Does AuroraMed provide rounding, handoff and sign-out tools?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. For reference, REQ-0433 (a high-priority requirement, the medium and large tiers) says the system must provide rounding, handoff and sign-out tools. Check: handoff report prints and displays.

C0643Does AuroraMed provide pathways/protocols and order sets under clinical governance?

The system must provide pathways/protocols and order sets under clinical governance. That is REQ-0434, a high-priority requirement for the medium and large tiers. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Test in the specification: order sets show version and owner.

C0644Does AuroraMed provide CDI query and response workflows?

Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. REQ-0435 says the system must provide CDI query and response workflows. Its acceptance check: query wording follows non-leading policy.

C0645Does AuroraMed support digital signature with ICP-Brasil certificates where the profile requires?

REQ-0436 is a high-priority requirement for all three tiers: the system must support digital signature with ICP-Brasil certificates where the profile requires. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. To verify it, the specification says signed document verifies against the trust chain.

C0646Does AuroraMed provide patient education library integration with language and reading-level metadata?

The clinical documentation and the chart part of the specification (REQ-0437) says the system must provide patient education library integration with language and reading-level metadata. Coming, not available: Wave 2 is still being built, and this item has no test evidence yet. Acceptance check: delivered education recorded with version.