Ehr Governance Packets

EHR quality-governance packets & audits

A family of tasks: you are given a short prompt, an answer_template.json, and read-only access to an EHR/referral environment (patients, conditions, medications, allergies, encounters, immunizations, disclosures, documents, service-requests, duplicate candidates, referrals, audit-logs, providers, an ICD-10 reference, and a service-code reference). You return one JSON object that matches the template exactly. The template — not your prose — defines the keys, types, enums, required_value fields, and ordering. There is no scoring tool available while solving a real task; rely on the rules below and on faithful reading of the environment.

Universal workflow

1. Read answer_template.json first, then the prompt. The template is authoritative. Note every key, enum set, required_value (e.g. a fixed task_id), type (incl. nullable), array set_semantics, and each array's ordering rule. Your output must have exactly those keys/types.
2. List the case objects named in the prompt: patient id(s), duplicate-candidate id, referral id(s), ServiceRequest id, batch id, recipient/receiving provider id, etc.
3. Gather evidence from the read endpoints described in the task's own environment-access file (use whatever base URL and routes that file provides). Pull the relevant record families: patient demographics, active clinical lists, encounters, documents, immunizations, disclosures, the duplicate candidate / referral / ServiceRequest object, the provider directory, and the ICD-10 / service-code references for any codes involved. A record family that isn't relevant to the template can be skipped.
4. Apply the domain rules (below) that correspond to the packet type.
5. Normalize and sort every array per the template, set required_value fields, and emit JSON only — no commentary, no trailing prose.

Reading records: status, normalized_key, faithfulness

• Condition/medication/allergy records carry status and a normalized_key. "Active" means status == "active". Entries with inactive / entered-in-error are not active.
• Active-key unions/lists = the set of normalized_key values over every active record, deduped across sources and (for merges) across both patients, then sorted per the template (usually ascending/alphabetical).
  • Include all active keys — even generic-looking placeholder keys (e.g. baseline_*) and duplicated allergens. A comprehensive active list keeps everything active. (Dropping such placeholders from a comprehensive list is wrong.)
• "excluded"/"distractor" key buckets = records whose status != active, by normalized_key.
• Copy verbatim: ids, dates, phones, faxes, codes, descriptions, and source strings come straight from the environment; don't paraphrase them.

Selection depends on the field's PURPOSE (the central judgment)

The same raw data feeds different fields with opposite selection criteria — always read what the field is for:

• Comprehensive / preservation lists (merge unions, care-transition active lists): keep all active records, placeholders included.
• Relevance-filtered lists (referral-letter diagnosis/medication highlights): keep only records tied to the stated reason and drop placeholders/distractors.

Distractor patterns to actively reject

See references/field-conventions.md for the full list. In brief: name collisions (same display name but different DOB/insurance = different people), placeholder normalized_keys, routine chart_summary/ehr_export documents, inactive records, audit-logs for other patients or unrelated/test events, and soft coordination notes ("confirm …") that don't actually change a complete record. Include or exclude each strictly by the field's purpose.

Packet-type rules

A. Duplicate merge-readiness / duplicate review

• Read the candidate for status, match_signals, conflict_signals, and merge_preview (preferred_target_patient_id/source_patient_id). Validate each signal against the two patients' actual demographics/conditions before emitting it.
• Target/canonical = the patient with canonical_status == "active" (the other has duplicate/possible_duplicate, or the candidate names the preferred target); source = the other. When no merge is decided, target/source are null.
• Disposition ladder (map to whatever enums the template gives):
  • Strong matches + only trivial/normalizable conflicts (address abbreviation like "St" vs "Street", a name nickname/variant) → clean ready / merge-ready. Still record the difference as a conflict_signal/demographic_conflict, but do not downgrade the disposition, set manual_review_required, or add a review note.
  • Strong matches and substantive conflicts (opposite-laterality problems, genuinely different given names, different phone) on an unresolved candidate → needs_review / review_hold with null merge target/source. (This is the correct outcome for a "twins-like" pair: same DOB/insurance/address but different name/phone and opposite-side problems — hold, do not jump to do_not_merge.)
  • Reserve do_not_merge for clear different-people-with-no-merge-value; reserve merge/confirmed for clean confirmed duplicates.
• Reconciliation (patient_active_list_endpoints_over_duplicate_preview): keys added = active keys from the patient endpoints minus the keys already in merge_preview, per category.
• demographic_matches = demographic fields whose values are equal across the two patients (dob, family_name, insurance_id, phone, sex). demographic_conflicts = fields that differ (given_name, address), including variant/abbreviation differences.
• Evidence documents follow the template's document_selection_policy (e.g. identity-verification + external clinical-continuity docs, status final). Routine chart_summary/ehr_export docs are excluded → put them in the distractor bucket and name the excluded type. Evidence audit_ids = audit entries for these patients that reference this case; other-patient / unrelated / test-tagged entries are distractors.
• packet_contact: specialist_provider = the provider matching the external continuity document's facility/service line; primary_care_provider = the patient's PCP block. Copy provider fields from the directory.

B. Referral coordination packet (specialty letter)

• patient_referral from the referral object (batch_id, service_line, requested_date) + patient.
• referral-relevant conditions and supporting codes = only codes clinically tied to the referral reason: the referral's own diagnosis_code and the presenting symptom in the narrative. Comorbidities are referral_relevant=false even when one of their medications is still highlighted.
• ICD validation via the ICD reference: valid_matches_narrative when the code's chapter fits the service line and the narrative matches the code's expected_terms; also emit the chapter and narrative_match.
• allergy_readiness: a single fully-populated active allergy (allergen+reaction+severity+status) = complete_documented, ready, no follow-up — even if a coordination note says "confirm …" (that note is a soft distractor; the record is complete). Letter enums offering a fully-specified allergy statement confirm completeness.
• recent_encounter_evidence = the encounter whose notes/diagnoses match the referral reason (not necessarily the most recent visit).
• medication_highlights = only referral-relevant meds; exclude placeholder/distractor meds (e.g. a baseline_* med with an implausible route).
• Letter-field enums: choose each value to match the derived facts; the option names themselves are strong hints about the intended answers.

C. Care-transition handoff packet

• Recipient = the named provider (from the directory). disclosure = the disclosure whose recipient_provider_id == recipient and status == "permitted".
• Handoff encounters = the N (template length) most relevant recent encounters for this transition — those tied to the transition's condition/service (e.g. the numbered handoff/ care-transition series about the surgical joint), newest→oldest. Not merely the most-recent encounters: exclude unrelated specialties, other body regions, and stale overflow beyond N. Record selected ids (newest→oldest) and all reviewed-but-excluded ids (ascending).
• latest_immunization = the immunization with the max date.
• risk_flags (from the template's allowed_values) derived from evidence: a condition (memory-loss → cognitive flag; hypertension → hypertension flag), a condition+medication combo (insulin + diabetes → insulin-dependent flag), an allergy (latex → latex-allergy flag), and encounter notes that explicitly require a plan/note (→ fall-risk-note-required, perioperative-glucose-plan-needed). risk_flag_evidence links each flag to its supporting active condition/medication keys (and the encounter carrying a note-based requirement).
• Readiness: ready_with_risk_flags when flags exist but nothing blocks; blocking_issue_codes come only from the template's missing_* / not-permitted enum — clinical requirements (glucose plan, fall-risk note) are risk flags, not blockers. ready only if no flags; not_ready only if a real blocker exists.

D. ServiceRequest quality check

• Copy scalar fields verbatim. service_code_valid via the service-code reference (code active and its service_line consistent with the performer). performer_service_line from the performer provider. reason_code_validation per code (ordered by code): valid = code exists in the ICD reference; chapter = its ICD chapter; matches_patient_evidence = the patient has an active condition carrying that code (any source counts, including imaging/MRI reports).
• SBAR coverage: complete=true when all four sections (situation, background, assessment, recommendation) are present and non-empty; emit sections_present + missing_sections.

E. Referral batch audit

• Scope the batch by filtering all referrals to the batch id yourself (a batch_id query param may be ignored by the server). record_count = row count (duplicate resubmissions count); unique_patient_count = distinct patient ids.
• invalid / out-of-range codes = codes whose ICD chapter is clinically wrong for the batch's service line (e.g. a Respiratory code in an orthopedic batch). Injury-chapter S-codes (meniscus tears, etc.) are acceptable for orthopedics — do not flag them as out-of-range. Use unknown_code only for codes absent from the ICD reference.
• laterality/narrative mismatch: compare the code (its expected_terms + laterality) to the narrative — laterality_mismatch (opposite side, same region), missing_laterality (same condition, no side stated), narrative_mismatch (different region/condition). Do not over-flag: a generic-symptom narrative that matches the code's region+side is not a mismatch, and prefer a single dominant mismatch_type per row rather than stacking types.
• duplicate_groups = same-patient resubmissions (a "-DUP" id / a "duplicate resubmission" coordination note); disposition = consolidate-under-original; tier all group rows as tier-1 duplicate blockers.
• insurance/patient anomalies = shared insurance id across different patients (e.g. twins) → verify-membership, do-not-merge. Same display name but different insurance/DOB is a distractor, not an anomaly.
• follow-up queues from referral fields: authorization missing/pending from authorization_status; records-request = referrals lacking an office-note document; imaging follow-up = missing/pending imaging.
• action_plan tiers: Tier 1 = urgent-urgency coding errors + invalid/out-of-range codes + duplicate blockers; Tier 2 = routine coding/auth/document blockers; Tier 3 = administrative document completion only. owner_provider_id = the referral's receiving provider. Every referral needing action is tiered once; count fully-clean rows as validated-ready.
• summary_counts are derived from the sections above — compute them from your own arrays, never independently.

Output discipline

• JSON only; exact template keys, types, enums, and required_values.
• Sort each array as the template says (default alphabetical/ascending; honor "newest→oldest", "by code", or "by id" when stated). Treat set_semantics arrays as unordered sets of the correct members.
• When a value is genuinely absent, use the template's nullable/missing option rather than inventing one.
• Prefer the smallest correct set: false-positive members (extra ids, over-flagged rows, guessed controlled-vocabulary codes) cost as much as misses.