szmc-clinical-notes

name

szmc-clinical-notes

description

Generate professional SZMC ward clinical notes in exact institutional format. PRIMARY: geriatric/internal medicine admission (קבלה רפואית), discharge (סיכום שחרור / סיכום אשפוז), consultation letters (ייעוץ), rehab admission (קבלת שיקום), rehab daily rounds (ביקור רופא בשיקום), and rehab discharge (סיכום אשפוז שיקומי). Secondary: ED discharge. Trigger on: "כתוב לי קבלה", "כתוב סיכום שחרור", "ייעוץ", "קבלת שיקום", "ביקור רופא", "rehab round", "daily round", "סיכום אשפוז שיקומי", "rehab discharge", "draft a note", or patient data upload. Auto-runs geriatric pharm analysis for ward notes. Generates HTML export for Chameleon EMR paste.

SZMC Clinical Notes Skill

OUTPUT FORMAT — CRITICAL

Plain text only. No HTML, no tables, no markdown in the note itself. User copies each section into Chameleon EMR fields. Hospital system generates the printout.

• Labs inline prose: נתרן 136, אשלגן 4.8, CRP 18.4.
• Lab trends in discharge: PROSE ONLY, NO ARROWS — CRP בקבלה 7.72, חלף במהלך האשפוז ל-1.35 בשחרור. Single > is reserved for med tapers (Lantus 22 > 10-12), NOT lab trends — Chameleon mangles arrow chains in lab section.
• Medications: one per line in SZMC format
• Problem headers use # as plain text (ward notes only, not ED discharge or consults)

• headers should be short and disease-focused: # עיניים not # MGD Blepharitis עם יובש

• תוכנית is a bare verb list — no bullets, no numbers
• Lab values: pull exact numbers, never round
• המלצות בשחרור and המשך טיפול תרופתי = DASH list (-) (Eias 28/04/26 — easier to delete items without renumbering; EMR auto-numbers drug list anyway)
• L/H suffixes from lab printouts: NEVER carry over — and do NOT replace them with any interpretation. Report the raw value only, no (מעל הנורמה)/(מתחת לנורמה), no high/low words. The reader interprets; the note reports. (Eias 04/06/26)

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CHAMELEON EMR PASTE RULES — CRITICAL

Validated against actual Chameleon rendering. Violations corrupt the note.

Forbidden

❌ Never use	Why	✅ Use
→ ← ↑ ↓ (Unicode arrows)	Render as ?	Single > for transitions
**bold**	Renders literally	Plain text, no bold
-- (double dash)	Encoding artifact	Single - or new line
>>>> (multiple >)	Visual noise	Single >
>200 <50	Flip in RTL	מעל 200, מתחת 50
q8h q6h qd bid	Confusing in Hebrew	כל 8 שעות, פעם ביום
Trailing ? after statement	Looks like encoding error	Rewrite or remove

Approved transition syntax — CONTEXT-DEPENDENT

Med tapers / regimen changes (NARRATIVE prose): Single > with spaces:

Lantus 22 > 10-12 יחידות
Furosemide IV 20 מ"ג פעמיים ביום > 40 מ"ג כל 8 שעות
Haloperidol PRN 2.5 מ"ג > 0.5 מ"ג מקסימום

Lab section trends (CRITICAL — no arrows, not even >): Use full Hebrew prose:

✅ קראטינין בקבלה היה 0.72, יציב במהלך האשפוז.
✅ סידן בקבלה 11.7, במהלך האשפוז 11.0-11.3, בשחרור 11.2.
✅ CRP בקבלה 7.72, חלף במהלך האשפוז ועמד על 1.35 בשחרור.

❌ סידן: 12.3 > 11.6 > 9.8 (20/04)    ← arrows corrupt in lab paste field
❌ קראטינין: 1.55 > 1.42 > 1.03      ← same
❌ Hb 10.8 → 10.9             ← Unicode arrows always forbidden

The lab paste field in Chameleon is more sensitive to non-Hebrew formatting than the narrative. Use prose only.

Section headers

Plain Hebrew word + colon. No asterisks, no decoration:

תרופות להפסיק היום:
Clonazepam 0.5 מ"ג - לא מומלצת בקשישים

Word choice — clinical terminology, not literal Hebrew calques (Eias 16/06/26)

Use the term a real ward doctor writes — the established medical term, frequently an inline English clinical term, NOT a literal Hebrew translation of an English concept. Literal calques read AI-generated and undermine the note's credibility. Israeli clinical notes naturally mix English medical terms into Hebrew prose.

❌ AI-vibe Hebrew calque	✅ What a doctor writes
שבר שבריריות / שבר שבירות	שבר פתולוגי (or fragility fracture inline)
רפלוקס ושטי	GERD
קיפופלסטיה	kyphoplasty
צליעה ספינלית	neurogenic claudication
היצרות תעלת השדרה (as a calque)	lumbar spinal stenosis (English inline)
אנמיה בתר-ניתוחית	אנמיה לאחר ניתוח / post-operative anemia; normocytic
כשל בטיפול (vague)	treatment failure

This is complementary to — not in conflict with — the JARGON RULES below. The jargon rule bans specialist abbreviations (Beers, STOPP, CFS, BPSD) toward non-geriatric/lay readers; the word-choice rule bans awkward literal Hebrew in favour of the standard medical term. Unifying test: write exactly what an Israeli ward physician writes — standard terminology (often English inline), neither obscure specialist jargon nor a translated-sounding calque.

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MIXED-LANGUAGE BIDI RULES — BATTLE-TESTED

The drug card pattern — USE THIS

For any medication recommendation, structure as 2-3 line "drug card". Always safe:

Clonazepam 0.5 מ"ג
תרופת הרגעה לא מומלצת בקשישים עם מחלת ריאות

Pregabalin 150 מ"ג
להפחית עד 75 מ"ג למשך 3 ימים ואז להפסיק לחלוטין

Paracetamol
1 גרם דרך הווריד כל 6 שעות קבוע
במקום לפי צורך, למשכך כאב בטוח ולהפחתת אופיאטים

Line 1: drug name (+ dose if short). Line 2+: pure Hebrew instruction.

Safe patterns confirmed

✅ One English word per line, at start OR end (not both) ✅ Drug name + pure Hebrew description on next line ✅ Taper as להפחית עד N מ"ג למשך X ימים (no מ-X ל-Y with English) ✅ Dates DD/MM/YY stable in Hebrew sentence ✅ Numeric range pure Hebrew: מ-60 עד 514 stable ✅ English terms in comma list: TSH, B12, חומצה פולית stable

Unsafe patterns — will flip

❌ Melatonin 3 מ"ג לפני שינה במקום Trazodone — English at both ends ❌ לטייפר Pregabalin מ-150 ל-75 מ"ג — taper range with English drug ❌ להעביר Paracetamol 1 גרם דרך הווריד כל 6 שעות — English mid-sentence

Fix: two short lines

Instead of Melatonin 3 מ"ג לפני שינה במקום Trazodone:

להפסיק Trazodone
להתחיל Melatonin 3 מ"ג לפני שינה

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GERIATRIC CONSULT SCOPE — STAY IN LANE

IN-LANE — specific recommendations OK

• HAP/CAP/UTI/SSTI/C. diff: specific empiric ABX per SZMC DAG (always project_knowledge_search first)
• Deprescribing: specific drugs to stop/taper
• Delirium pharm: Haloperidol 0.25-0.5 mg PRN, Quetiapine 12.5-25 mg bedtime
• Delirium non-pharm: reorientation, sleep, mobility, sensory aids
• CHF basics: diuretic titration, K monitoring, spironolactone
• Electrolytes: specific correction protocols
• Renal dose adjustment: for all recommended drugs
• VTE prophylaxis: Padua, pharm vs mechanical
• Pain: Paracetamol scheduled, opioid titration
• Glycemic de-intensification in frailty
• Functional/cognitive assessment
• Israeli legal framework: capacity, surrogate decision-maker

OUT-OF-LANE — refer generally

• Cholangitis/hepatobiliary workup (MRCP, ERCP, biopsy) → גסטרו
• Surgical candidacy → כירורגיה
• Quantitative oncology prognosis → אונקולוגיה (don't give numbers)
• Invasive cardiology (cath, TAVI) → קרדיולוגיה
• Specialty-specific imaging beyond routine

Referral language

לדיון עם גסטרו לגבי המשך בירור כבדי
לשקול התייעצות כירורגית להערכת הקולקציה באגן
לשקול התייעצות אונקולוגית לגבי סטטוס המחלה
לבירור מול המחלקה האחרונה לגבי טיפולים קודמים

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JARGON RULES — WRITE AS TO A LAYPERSON

Non-geriatric teams do NOT know geriatric terminology. Imagine a family member or nurse reading the note.

Forbidden in consults to non-geriatric teams

❌ Never use	✅ Plain Hebrew
CFS, Clinical Frailty Scale	מטופל סיעודי, תלוי לחלוטין בטיפול, מצב כללי חלש מאוד
Frailty, פרגיליות	מצב כללי חלש
Deprescribing	להפסיק תרופות מיותרות
Beers, STOPP, START	(omit — just explain why drug inappropriate)
ACB, Anticholinergic burden	תרופות שמחמירות בלבול בקשישים
Polypharmacy	ריבוי תרופות
BPSD	הפרעות התנהגות על רקע דמנציה
CAM positive	בלבול פעיל, דליריום פעיל
PAINAD	הערכת כאב במטופל שאינו מתקשר
Sarcopenic obesity	תת-תזונה למרות השמנה

Goals of care — DO NOT raise proactively

Do not include GOC recommendations in routine consults. Treating team + oncology + family own that conversation.

Raise only if:

• Specifically asked by consulting team
• Imminent end-of-life (hours-days)
• Capacity/surrogate question (Israeli legal) — then refer to עו"ס
• Discharge note where GOC was actually discussed with patient/family — then it lives as # טיפול יעדי (Goals of Care) inside מהלך ודיון, not as a top-level section

When needed in a consult, frame indirectly:

לשקול בהתאם להעדפות המטופל והמשפחה

Audience awareness

• To another geriatrician: jargon OK (rare)
• Internal ward tracking: jargon OK
• To non-geriatric team: plain Hebrew only

NO glossary section

Never append a "מילון מונחים" / glossary to discharge notes. If a term needs explaining, expand it inline once: ESBL (חיידק עמיד רחב טווח). The receiving GP doesn't need a vocab list.

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WORKFLOW

1. Collect patient data
2. Determine note type — then apply the REHAB_NOTES.md load gate.

• Note types: ward admission (קבלה) / discharge (סיכום אשפוז) / consult (ייעוץ) / ED discharge / rehab admission (קבלת שיקום) / rehab daily round (ביקור רופא) / rehab discharge (סיכום אשפוז שיקומי).
• LOAD GATE — read REHAB_NOTES.md (the ~48KB sibling) if and ONLY if the note being written is one of the three rehab types: rehab admission (קבלת שיקום), rehab daily round (ביקור רופא / daily round for a patient already on the rehab ward), or rehab discharge (סיכום אשפוז שיקומי — including a generic סיכום אשפוז when the patient's current ward is rehab). Any one of the three OPENS the gate on its own — including a bare ביקור רופא / daily round, or a generic סיכום אשפוז, for a patient currently on the rehab ward, even when the word שיקום/rehab does not appear. When open, read it in full before drafting.
• Gate CLOSED for every non-rehab note (plain admission, discharge, consult, ED): do NOT read REHAB_NOTES.md — this includes a plain acute discharge whose disposition is rehab (a transfer-to-rehab plan from an acute ward is not a rehab note; contrast a discharge of a patient already on the rehab ward, which IS a rehab discharge — gate open per above). The gate keys on the note type and the patient's current ward, not on whether the word שיקום/rehab appears; loading it into a non-rehab note only adds latency plus bleed-in risk (rehab functional templates leaking in).

3. Search project knowledge for drug dosing, DAG antibiotics, guidelines
4. Draft note in plain text, section by section in printed-output order (see below)
5. Run geriatric analysis (ward notes only, show in chat AFTER note, NOT in HTML)
6. PRE-DELIVERY: skeleton-section self-check. Scan every copy block for (a) lines that are bare section/topic headers (מצב כללי, לב, ריאות, בטן, שינה, תאבון, כאב, מצב רוח) without clinical data, and (b) [...] bracket placeholders. If any are found, the note is not finished — draft real prose before exporting.
7. Generate HTML export — RTL, David font, section divs with copy buttons
8. If empiric ABX needed: always search SZMC DAG first

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SECTIONS — PRINTED-OUTPUT ORDER (gold standard)

Admission (קבלה)

כותרת > הצגת החולה > אבחנות פעילות > אבחנות ברקע > ניתוחים בעבר > תלונה עיקרית > רקע רפואי > מחלה נוכחית > רגישויות > תרופות בבית > הרגלים > תפקוד > בדיקה גופנית > בדיקות עזר > בדיקות מעבדה > דיון ותוכנית > חתימה

Admission מחלה נוכחית — risk scores close the HPI (house pattern, verified 04/06/26 admissions)

The HPI ends with the relevant risk scores, inline, as the final lines — NOT in a separate scores field. Whichever apply to the case:

padua score: 8
CHADS2: 3

Padua on essentially every geriatric admission (VTE-prophylaxis decision); CHADS2 / CHA2DS2-VASc when AF is in the picture. Compute from the chart, place last, no commentary.

Admission דיון ותוכנית — the discussion block (verified 04/06/26 admissions)

Acute admissions open the discussion with a fixed scaffold, THEN a #-prefixed problem list (NOT * — see below), each problem carrying its own reasoned differential:

רקע כמתואר לעיל.
[restate the precipitating event]
סימנים חיוניים: ל"ד X, דופק X, חום X PO, סטורציה X% באוויר חדר, נלקח HH:MM DD/MM
[ED course / consults / key labs + imaging]

המטופל מציג את הבעיות הבאות להתייחסות:

# זיהומי
[reasoning]
באבחנה המבדלת:
1. ...
2. ...

# כלייתי
...

# סטטוס
...

תוכנית:
[bare verb list — no bullets, no numbers]

Mandatory # סטטוס problem. Every acute geriatric admission resolves code status — and resolves it against the named legal authority, never the patient directly. Two patterns:

• Decision deferred: בשיחה עם [בת/בן] המשפחה שהוא/היא היפוי כוח לגבי סטטוס, תעדכן בבוקר.
• Decision made: בשיחה עם [the proxy] שהוא/היא האפוטרופוס, הוסבר המצב, המטופל DNR/DNI. Name the proxy role (היפוי כוח / אפוטרופוס), state the conversation happened, give the decision or the defer-to-morning. Do NOT write proxy/family proper names — בת המשפחה, האפוטרופוס, per the no-names rule.

Provenance line when history is unreliable. Non-communicative dementia / poor-historian patients get an explicit source line in מחלה נוכחית: מטופל לא משתף פעולה, אנמנזה נלקחה מתיעוד באזמה ומדיווח מד"א.

# alarm notation. A dangerous interval trend is flagged inline with (!): המוגלובין 10.6 בירידה מ-13.2 יום קודם (!).

Problem-list marker — # not *. Real night-team admissions are split: some dictate *זיהומית / *תפקודית / *סטטוס, others #. House standard for our output is #. When inheriting/cleaning a source dictation, convert every * problem header to # — do not preserve the source's asterisks.

Admission תפקוד subsection format — VERIFIED the functional-subsection print print

The admission תפקוד field is a structured subsection, not free prose. Use these labels in this order:

מגורים: מתגורר בבית / בבית אבות / מוסד סיעודי
עזרה: עצמאי / עזרת משפחה / עזרת מטפלת זרה / מטפלת ישראלית
התמצאות: שמורה / דמנציה / חלקית
הזנה: כלכלה רגילה פומית / טחונה / IDDSI N / PEG / NG
הלבשה: עצמאי / עזרה חלקית / עזרה מלאה
רחצה: עצמאי / עזרה חלקית / עזרה מלאה
אכילה: עצמאי / עזרה חלקית / עזרה מלאה
הכנת אוכל: עצמאי / עזרה חלקית / עזרה מלאה
ניידות: עצמאי / עזרה חלקית / עזרה מלאה
ניידות בכיסא גלגלים: עצמאי / עזרה חלקית / עזרה מלאה
מעברים: עצמאי / עזרה חלקית / עזרה מלאה
שליטה על שתן: עצמאי / עזרה חלקית / עזרה מלאה
שליטה על יציאה: עצמאי / עזרה חלקית / עזרה מלאה

Key rules:

• ADL items use a fixed 3-tier grading: עצמאי / עזרה חלקית / עזרה מלאה. No other terms.
• Do NOT use the MRS (Modified Rankin Scale) in admission notes — it is not part of the standard SZMC admission ADL section. If functional severity needs a one-liner summary in מהלך ודיון or in הצגת החולה, use plain Hebrew (סיעודי, מרותק למיטה, תלוי לחלוטין) not "MRS 5".
• Each line is label: value — no commentary, no qualifiers like "כנראה" or "מדווח".
• The ADL subsection IS the source of truth for all downstream # תפקוד summaries (in מהלך ודיון and in discharge notes). Don't restate; reference.
• All items per ADL: include even if עצמאי for everything — completeness signals you actually assessed.

Discharge (סיכום אשפוז) — REVISED per the discharge-format print print

This is the printed output order as it appears on the SZMC letterhead. Each section below maps to a paste field; the system assembles it in this sequence:

1. כותרת (auto: letterhead, demographics, תנועות table)
2. אבחנות פעילות — ACUTE ADMIT REASON ONLY (chronic conditions go to ברקע). Add BLOOD TRANSFUSION X N units if patient received any units during stay. English UPPERCASE optionally with Hebrew label (Hebrew). Modifiers: - Resolved, - Resolving, , Recurrent, M/P. Always check Type 2 MI in elderly with sepsis/shock.
3. ניתוחים באשפוז — NGT / urinary catheter / PEG insert/remove events from the AZMA tube icon (hover shows dates). SKIP peripheral IV (gets stripped, not clinically tracked). If no tube events during admission, leave blank.
4. אבחנות ברקע — chronic conditions, English UPPERCASE. EMR auto-merges "אבחנות בעבר" entries here — audit pre-populated entries for staleness/duplicates but don't auto-delete (they were entered by prior admissions for a reason).
5. הצגת החולה — single line (e.g., בת 90, נשואה, הגיעה מרפואה דחופה-מיון, מתגוררת בבית עם המטפלת)
6. תלונה עיקרית — 1-2 lines
7. מחלה נוכחית — CAUTION: This field APPENDS to the admission text in the EMR, it does not replace. Approach: read the existing admission paragraph, audit for typos/voice-rec errors/missing info, output a cleaned version for retro paste-over. The doctor manually clears the old text and pastes the audited version while writing the discharge.
8. רקע רפואי — פרוט מחלות: (organ-system dash format) + אבחנות בעבר: (English UPPERCASE list) + פרוט ניתוחים/פעולות + ניתוחים בעבר
9. רגישויות — list with reactions (or לא ידוע / לא התקבל מידע)
10. הרגלים — מעשן: לא / שימוש באלכוהול: לא / שימוש בסמים: לא
11. בדיקה גופנית בקבלה — vitals + system exam from admission
12. תרופות בבית (auto sidebar from Chameleon DB) — Title Case format. Inherits Chameleon's casing — do NOT force ALL-CAPS here.
13. בדיקות עזר (פירוט) — discrete section, BEFORE labs: cultures FIRST (with full sensitivity panel), then imaging reports verbatim, then procedures. NEVER labs. Date OK; STRIP all of: reporting doctor names (radiologist/pathologist), accession numbers, vial IDs, מספר בדיקה.
14. בדיקות מעבדה — CATEGORIZED PROSE TRENDS, NO ARROWS (Eias 28/04/26):

• Categories: ביוכימיה / מדדי דלקת / ספירת דם / גזים (separate paragraphs)
• Format: <param> בקבלה X, במהלך Y, בשחרור Z
• Max 2-3 numbers per parameter — do not list 5 timepoints of the same lab
• Drop redundant: if Cr listed, omit eGFR and BUN (covered)
• Total Ca → correct for albumin if same-day specimen has both. Formula: Corrected Ca = measured + 0.8 × (4.0 − albumin). Cite the corrected value when albumin <4.0. Ionized Ca needs no correction.
• RAW VALUES ONLY — no interpretation (Eias 04/06/26): no L/H suffix, no (מעל הנורמה)/(מתחת לנורמה), no high/low words. Just the number, e.g. אשלגן 5.6.
• Full lab table auto-appends from EMR after this section anyway — keep curated section focused on clinically relevant moves

15. מהלך ודיון — MUST OPEN with the patient summary template (Eias 28/04/26):

בת X סיעודית עם דמנציה, מרותקת למיטה, מוזנת דרך PEG... [demographics + functional + key chronic conditions] עם הרקע הנ"ל -

התקבלה בשל [acute presentation]
במיון בבדיקת [vitals + exam]
במעבדה (כולל בדיקות עזר) [labs + imaging summary]
[ייעוצים במיון אם היו]
אושפזה בשל [reason] במחלקתנו [purpose]
בקבלתה למחלקה [exam + labs comparison to ED]

במהלך אשפוז הציגה את הבעיות הבאות להתייחסות:

THEN # headers per problem (disease-focused & short). # טיפול יעדי only if a documented decision was made (don't auto-add for speculative GOC). # תפקוד always last. 16. המלצות בשחרור — DASH list (-) (Eias 28/04/26 — easier to delete items without renumbering). Brief references to PT/OT/dietician (הפניה לפיזיותרפיה בבית, הפניה לריפוי בעיסוק בקהילה). WARNING: each bullet must be ≤ ~180 chars or Chameleon truncates mid-word. Drop generic boilerplate: skip במקרה של החמרה - פנייה למיון and להביא סיכום אשפוז זה לכל פנייה רפואית עתידית. Skip generic dietician follow-up if dietician already saw inpatient. Keep clinically actionable items only. 17. המשך טיפול תרופתי — DASH list (-) (EMR auto-numbers anyway — system overrides our format). Title Case auto-format from Chameleon DB. For PEG patients, ALWAYS add Water (Water) per gastrostomy 400 ml X 3 / d לפי צורך. Borderline home meds (Furosemide etc.) → keep on PRN with מינון לפי צורך, לפי החלטת רופא מטפל rather than deprescribing in the discharge print (defer that decision to outpatient clinic). 18. (auto-appended) — full lab table + cultures table + PT functional assessment block (signed by PT herself) 19. חתימה — see signature section

Drug name casing — narrative vs. drug-list sections

Section type	Casing	Example
Narrative prose (מחלה נוכחית, מהלך ודיון, # headers)	ALL-CAPS English	בטיפול ב-CEFTRIAXONE (ROCEPHIN), החל NORADRENALINE, הוחלף ל-PIPERACILLIN-TAZOBACTAM (TAZOCIN)
תרופות בבית (auto sidebar)	Title Case (Chameleon DB)	Bisoprolol fumarate (Concor)
המשך טיפול תרופתי (auto from continued meds)	Title Case (Chameleon DB)	Olanzapine (Olanzapine -teva)

Don't fight Chameleon's auto-format on the drug-list sections. Only force ALL-CAPS where you're typing free narrative.

REMOVED from discharge (do not produce):

• ❌ תרופות באשפוז (in-hospital med list) — not in printout
• ❌ מילון מונחים (glossary) — not used
• ❌ Full PT/OT/dietician prose blocks in main body — these go elsewhere (see Allied Health below)
• ❌ Standalone # AF, CHADS-VASc style mini-sections unless management actually changed
• ❌ # חסך ויטמין D קשה as standalone — fold into the relevant problem (e.g., # היפרקלצמיה)

Consult (ייעוץ)

כותרת (ייעוץ גריאטרי + תאריך + מטופל + מחלקה מפנה + יועץ) > סיבת הייעוץ > דיווח > הערכה > המלצות תרופתיות (להפסיק/להוסיף/לשנות מינונים) > טיפול לא-תרופתי > בדיקות להשלמה > הפניות > ביקור חוזר > חתימה

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REHAB NOTES — admission and daily rounds

Full rehab logic — rehab admission inheritance pattern, the three-pattern daily round (FIRST-DAY / STABLE / COMPLEX), rehab discharge (סיכום אשפוז שיקומי), the complex-medical rehab-discharge checklist, and the rehab clinical pearls — lives in REHAB_NOTES.md (sibling of this file). Load it per the WORKFLOW LOAD GATE (step 2): read REHAB_NOTES.md in full before writing for a rehab admission (קבלת שיקום), rehab daily round (ביקור רופא), or rehab discharge (סיכום אשפוז שיקומי) — and not at all for any non-rehab note. For bedside speed during rounds, the rehab-quickref skill remains the companion quickref.

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ALLIED HEALTH (DISCHARGE) — REVISED

PT, OT, and dietician do NOT belong in the doctor's narrative body. Each is handled separately in the Chameleon system:

• פיזיותרפיה (PT) — auto-attaches to the end of the printout, written and signed by the PT herself (block titled מצב תפקודי לפי הערכת הפיזיותרפיה). Doctor does not write this.
• ייעוץ תזונה (Dietician) — pastes into its own sub-tab under המלצות בשחרור (the "ייעוץ תזונה" sub-button). Doctor does not write a full nutrition prose block.
• ריפוי בעיסוק (OT) — pastes into its own sub-tab under המלצות בשחרור (the "ריפוי בעיסוק" sub-button). Doctor does not write a full OT prose block.

What the doctor DOES write:

• A single-line # תפקוד summary inside מהלך ודיון describing functional status and that PT was involved
• 1-2 numbered items in המלצות בשחרור referring out: הפניה לפיזיותרפיה במסגרת הבית (יט"ב), הפניה לריפוי בעיסוק בקהילה להערכת סביבה ביתית

If the user explicitly asks for a full PT/OT/dietician prose block (e.g., "give me text to paste into the dietician sub-tab"), then write it as a separate copyable section — but don't insert it into the main note.

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MEDICATION FORMAT

SZMC standard: [Generic] ([Brand Hebrew/English]) [Route] [Dose] [Unit] X [Freq] / [Period]

Furosemide (פוסיד) P.O. 40 mg X 1 / d
Apixaban (Eliquis) P.O. 2.5 mg X 2 / d
Hydroxyethylcellulose (V-teers) ocular 1 drop X 10 / d קבוע

Discharge Rx rules

• DASH list (-) as a list — EMR auto-numbers anyway in the print output
• PEG patients: ALWAYS include Water (Water) per gastrostomy 400 ml X 3 / d לפי צורך (flush water)
• NGT patients: same flush pattern with per NG tube
• Free water for PZ: Water (Water) per NG tube 350 ml X 3 / d
• PRN with indication + duration: Loratadine (Loratadim) P.O. 10 mg X 1 / d למשך 20 ימים — גירוד מפושט
• Time-limited (e.g., eye drops post-procedure): include למשך X ימים
• Side-specific (eye drops): עין שמאל or עין ימין or דו"צ
• Formula: NUTREN 2 per PZ 660 ml / d (30 ml/hr X 22h)
• Completed ABX → omit from discharge Rx
• Suspended/conditional drugs (e.g., prophylactic ABX paused during active treatment) → keep in list with explanatory note in parens about restart conditions
• Borderline home meds with unclear indication (Furosemide without clear HF/CHF, etc.) → DO NOT deprescribe in the discharge print. Keep on PRN with מינון לפי צורך, לפי החלטת רופא מטפל and defer the decision to outpatient clinic. Eias's standing rule: discharge isn't the place to make controversial deprescribing calls; flag and defer.
• Each line ends קבוע or לפי צורך

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KEY STRUCTURAL RULES

Problem headers (ward discharge notes)

Always # headers, disease-focused, short:

• ✅ # עיניים / # היפרקלצמיה / # בקטריוריה אסימפטומטית / # שברי דחיסה T12 ו-L1 / # בלבול / # היפונתרמיה / # AKI על CKD - חלפה / # אלקלוזה נשימתית / # טיפול יעדי / # תפקוד
• ❌ # MGD Blepharitis עם יובש בעיניים (too long)
• ❌ # Issue: Hypercalcemia of malignancy with secondary AKI (English narrative)

Header sequencing in מהלך ודיון:

Open with patient summary narrative (before any # header):

בת X סיעודית [+functional status] עם הרקע הנ"ל -

התקבלה בשל [acute presentation]
במיון בבדיקת [vitals + exam findings]
במעבדה (כולל בדיקות עזר) [labs + imaging summary]
[ייעוצים במיון אם היו]
אושפזה בשל [admit reason] במחלקתנו [purpose]
בקבלתה למחלקה [exam + labs comparison to ED]

במהלך אשפוז הציגה את הבעיות הבאות להתייחסות:

THEN # headers in this order:

1. Acute injury / chief presenting problem first
2. Cardinal metabolic/medical problem
3. Infection or culture-related items
4. Neuro (delirium, etc.)
5. Resolving problems (hypoNa, AKI)
6. Minor lab findings (alkalosis, vit D, etc.)
7. Consult-driven items (eyes, derm, etc.)
8. # טיפול יעדי only if a documented decision was made with patient/family/אפוטרופוס. Don't auto-add for speculative GOC discussions — that's premature and gets cut.
9. # תפקוד at the very end (always)

רקע רפואי format (admission AND discharge)

Two-part structure:

פרוט מחלות:
לבבי - פרפור עליות, אי ספיקת לב עם תפקוד סיסטולי שמור
וסקולרי - יל"ד
כלייתי - אי ספיקת כליות כרונית
המטולוגי - לימפומה ידועה במעקב בהדסה
...

אבחנות בעבר:
PSEUDOPHAKIA - PROSTHETIC LENS - BE

Diagnoses

Active (this admission): DIAGNOSIS - Suspected / DIAGNOSIS, RESOLVING / PALLIATIVE CARE / M/P (malignancy-related) / - Resolved / , Recurrent Background (chronic): IDA and SUBCLINICAL HYPOTHYROIDISM → always background. Add EF and date for HFPEF (HFPEF 60-65% EF 6/2024). Add level for fractures (FRACTURE OF VERTEBRAL COLUMN, T12/L1).

Plan patterns

Bare verbs. HOLD [DRUG] / [TEST] (?) / לשקול [ACTION]. Discharge המלצות בשחרור use DASH list (-).

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LAB SECTION RULES — VERIFIED 28/04/26

Categorization (REQUIRED)

Group labs by category in the מעבדה section. Each category is its own paragraph:

ביוכימיה:
[creatinine, calcium, phosphate, albumin, glucose, etc.]

מדדי דלקת:
[CRP, procalcitonin if measured]

ספירת דם:
[Hb, WBC differential summary, platelets if abnormal]

גזים בקבלה (וריד / עורקי):
[PH, PCO2, HCO3, lactate, ionized Ca]

וירוסים / תרביות:
[goes in בדיקות עזר section, not here]

Prose, not arrows

Format: <param> בקבלה X, במהלך האשפוז Y, בשחרור Z [— interpretation]

Examples:

• קראטינין בקבלה היה 0.72, יציב במהלך האשפוז.
• סידן בקבלה 11.7, במהלך האשפוז בטווח 11.0-11.3, בשחרור 11.2.
• CRP בקבלה 7.72, חלף במהלך האשפוז ועמד על 1.35 בשחרור.

Max 3 numbers per parameter

Don't list 5 timepoints of the same lab. Pick: admission, mid-course (or extreme), discharge.

Drop redundant parameters

If you list creatinine, do NOT also list:

• eGFR (calculated from creatinine — redundant)
• BUN (usually moves with Cr — redundant unless clinically distinct)

Corrected calcium for total Ca

When reporting total calcium, calculate corrected Ca if a same-day albumin is available:

Corrected Ca = measured Ca + 0.8 × (4.0 − albumin)

• Cite the corrected value when albumin <4.0 g/dL
• Ionized Ca needs no correction — it's already the "true" value
• Worked example: Ca 11.2, Albumin 3.0 → Corrected = 11.2 + 0.8×(4.0−3.0) = 12.0
• Always show the math impact when the corrected value crosses a clinically meaningful threshold (e.g., raw appears stable but corrected is rising)

Labs — RAW VALUES ONLY in the note; strip H/L & range-parens everywhere (Eias 04/06/26, scoped 06/23/26)

Report lab values exactly as the number. In the note's lab reporting, do NOT interpret — no H/L suffix from the printout, no (מעל הנורמה)/(מתחת לנורמה) parens, no "high"/"low"/"above"/"below" words on the figure. The clinician reading the note interprets; the note reports the figure.

Scope (Eias 06/23/26): this is a lab-value-rendering rule, not a gag on clinical reasoning. The chat / geriatric-pharm-analysis path MAY still interpret and flag clinically dangerous labs in prose (hyperkalemia, AKI, rising CRP, etc.) — that safety function is intended. But even in chat, never echo the printout's literal H/L suffix or normal-range parens: state the raw number, then the reasoning in words (K 5.6 — hyperkalemia, hold ACE-i, not K 5.6 H).

❌ NEVER	✅ Always
Ca 11.3 H	Ca 11.3
אשלגן 5.6 (מעל הנורמה)	אשלגן 5.6
Albumin 3.0 (מתחת לנורמה)	אלבומין 3.0
eGFR 68 L	(omit eGFR — covered by Cr)

בדיקות עזר section — what to strip

When pulling imaging/cultures into the discharge בדיקות עזר section:

Strip	Keep
Reporting radiologist name (the reporting radiologist)	Date (21/04/26)
Pathologist signature	Modality (צילום חזה, CT בטן)
Accession numbers (C089381)	Findings prose
Specimen IDs (K04211221)	Sensitivity panel for cultures
מספר בדיקה: 264056	נשאות ל-CRE: שלילי

The receiving GP doesn't need provenance metadata — they need the finding.

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RECOMMENDATION LENGTH GUARD — CRITICAL

Verified failure (two finalized discharge prints): Chameleon's המלצות בשחרור field truncates long bullets mid-word in the printed output. Both finalized notes lost text. This means the patient/family copy did NOT contain the full recommendation.

Hard rule

• Each המלצה bullet must be ≤ 180 characters (Hebrew chars count, including spaces and punctuation).
• Before producing the המלצות section, scan each bullet. If any bullet exceeds ~180 chars, split it into two consecutive dashed items rather than letting it get cut.

Self-check pseudo-rule

For each bullet:

if len(bullet) > 180:
  split at the most logical boundary (period, "ו-", ":", or change of subject)
  add a new dash line — no renumbering needed (it's a dash list)

Example — too long, will truncate

- במידה ויש נפילה חוזרת או החמרה במצב הקליני (תלונות חדשות, החמרה בקוצר נשימה, תלונות חזה, או חולשה משמעותית) יש לפנות בהקדם לרפואה דחופה ולהביא את סיכום השחרור מה אשפוז הנוכחי

216 chars → cuts mid-sentence in printout.

Fix — split into two

- במידה ויש נפילה חוזרת או החמרה במצב הקליני - פנייה למיון.
- להביא את סיכום השחרור מאשפוז זה לכל פנייה רפואית עתידית.

However: per Eias 28/04/26, drop generic boilerplate altogether — the two lines above are usually skipped from המלצות because they're useless redundancy. Print only clinically actionable items.

Cardiology / SGLT2i pattern (HFmrEF / HFpEF on discharge)

When discharging with new HFmrEF or HFpEF and DM2 — and beta-blocker / ACE-i held due to comorbidity (e.g., active asthma, AKI) — prompt the cardiologist for SGLT2i in the recommendations rather than starting it yourself. Format:

לשקול תחילת SGLT2i (Empagliflozin / Dapagliflozin) במרפאה הקרדיולוגית
- אינדיקציה כפולה: HFmrEF + DM2 (HbA1c X)
- בכפוף לתפקוד כליות eGFR > 25

This protects you (you didn't initiate without echo + cardiology buy-in) while planting the prompt where it'll get acted on. Same pattern for SGLT2i in CKD (eGFR-based), GLP-1 in obesity-DM2, finerenone in DKD-HFpEF, MRA in HFrEF post-discharge — when the right next-line is owned by another specialty, write the rec as "לשקול ... במרפאה ..." rather than no rec at all.

Active diagnosis discipline

• If you mention a problem only in דיון or in רקע פרוט מחלות, but it has follow-up implications, also surface it in אבחנות פעילות. Otherwise the next admission/family physician misses it.
• Common omissions to check before sending: Type 2 MI in any septic shock case, IDA workup status, new HF phenotype, new arrhythmia on telemetry, cancer surveillance findings, sinus opacification on incidental CT.

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GERIATRIC REQUIREMENTS (ward notes)

1. Functional baseline (pre-morbid AND current) — pulled from the structured admission תפקוד subsection (3-tier ADL grading, see "Admission תפקוד subsection format" above)
2. Mobility aid, cognitive status, caregiver, living situation
3. Padua score at end of מחלה נוכחית. CHADS2/VASc if AF.
4. Code status if discussed
5. PT/OT/dietician referrals in המלצות בשחרור (brief, numbered)
6. Delirium assessment if relevant
7. # תפקוד summary at end of מהלך ודיון (one-line distillation of the structured ADL section, NOT a restatement)

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AZMA EMR INTERPRETATION — when reading the patient list and med grid

Decoding the screenshot vs. interpreting it. To read an AZMA screen — medication-grid icons, the ניהול מחלקה census columns, status icons, cell colours — use the azma-ui skill, which owns AZMA screen decoding. Do not restate icon, column, or colour meanings in this skill — point to azma-ui, so the two cannot drift. The guidance below is about how to interpret a correctly-read active med grid for note-writing and clinical critique.

The AZMA הוראות תרופתיות grid shows active orders only. This has two consequences for note-writing and clinical critique:

1. Struck-through rows = held or discontinued. These are explicit clinical decisions and should be respected as such — don't "restart" them by reflex when writing a continuation plan.
2. Absent meds may be intentional clinical choices, not omissions. Examples: a stroke + PE patient without atorvastatin may have it on hold for transaminitis, drug interaction, or a documented decision to deprescribe. Do NOT auto-flag missing meds as "you should add X" in the geriatric analysis without first confirming the absence is unintentional.
3. Frailty changes the dosing math. A bedbound MRS 5 demented patient with PUD and recurrent UGI bleed history on prophylactic-range Clexane (40 mg ×2) instead of weight-based therapeutic (60 mg ×2) is making a defensible frailty-adjusted choice — not an undertreatment error. Apply guideline-medicine lens only after asking whether frailty changes the risk-benefit calculation.

When critiquing an active med list, frame as questions ("is X intentionally held?", "did you consider Y given Z?") rather than directives ("you missed adding X"). The doctor managing the patient has context the grid does not show.

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GERIATRIC ANALYSIS (chat only, not HTML, ward notes only)

📋 ניתוח גריאטרי — [Patient]
🔴 Critical 🟠 Warning 🔵 Gap 💡 Pearl

Max 10-12 flags. Domains: Beers 2023, STOPP/START, renal dose, interactions, falls, delirium, missing workup (cognitive assessment, bone protection, VTE, code status, TSH, HbA1c).

This section uses geriatric jargon — it's for the geriatrician, not for the consulting team or the discharge document.

Framing discipline (the functional-subsection print):

• When the active med grid is in front of you (AZMA הוראות תרופתיות), absent meds may be intentional. Frame "missing" items as questions not directives.
• Frailty-adjusted dosing (sub-therapeutic anticoag in a bedbound demented patient with bleed history) is defensible — push back on it only if the frailty reasoning is genuinely absent, not just because the dose is below the guideline number.
• Trend data deserves its own flag category. A persistently abnormal Hb across multiple admissions (e.g., 2018→2022→2026 trajectory) is more diagnostic than the current admission's point value.

Specific flags to always check on discharge:

• Carrying forward home benzos / Z-drugs (Brotizolam, Zolpidem, Clonazepam) after delirium episode → flag
• Apixaban dose reduction criteria — need ≥2 of 3 (age ≥80, weight ≤60 kg, Cr ≥1.5) to justify 2.5 mg BID; flag if downdosed without meeting criteria
• Vitamin D restart timing after hypercalcemia
• Mirtazapine carried at admission dose without reassessment
• Home prophylactic ABX (Nitrofurantoin, TMP-SMX) paused during treatment — restart logic documented?
• Empiric ABX narrowed to match culture sensitivity?

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SIGNATURE

Standard:

חתימת רופא: [שם]

Discharge — order matters in printout:

סיכום האשפוז סופי רק לאחר חתימת רופא בכיר
רופא בכיר: ד"ר [שם]
חתימת רופא/ה מתמחה: ד"ר Eias Ashhab מ.ר 000147224
תאריך חתימה: DD/MM/YY HH:MM

The senior cosignature line appears ABOVE the fellow's signature in the printed output, preceded by the warning line. If unsigned, print shows סיכום לא חתום × 3.

Eias's license number: 000147224 — bake into all discharge signatures.

Consult:

חתימה: ד"ר Eias Ashhab
מתמחה גריאטריה
DD/MM/YY

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PRE-DELIVERY SELF-CHECK — SKELETON SECTIONS ARE NOT DELIVERY

No skeleton sections. Every copy block must ship as real prose. A block whose lines are bare topic-words or contain a [...] bracket placeholder is not done — it is an empty section, regardless of character count. Char-count is not verification.

Lines that count as "empty"

• Bare section headers stacked vertically: מצב כללי / לב / ריאות / בטן (a list of headings a section would have is a scaffold, not the section itself)
• *תפקודית / *תרופתית followed by nothing
• [fill from nursing chart] / [bedside] / any […] bracket placeholder
• A whole block like שינה / תאבון / כאב with no values

Acceptable

Conventional exam defaults (לב - קצב סדיר, ללא איוושות, ריאות - אוורור תקין דו"צ) for the physician to confirm at bedside are legitimate note-drafting. Inventing specific measured numbers (a BP, a pulse, an O₂ sat) is not — when a measured value is genuinely missing, the honest line (סימנים חיוניים - להשלים מגיליון הסיעוד של היום) plus a flag in the team-flags box beats both fabrication and bare scaffold.

Self-check checklist (run before HTML export)

1. Read every copy block line-by-line, not by scrolling speed.
2. For each line: does it carry actual clinical data (a value, an observation, a finding, a decision)?
3. If a line is a bare header or placeholder: rewrite as real prose from the available docs (admission letter, AZMA orders, prior SOAPs, PT/OT notes) or replace with the explicit "complete from " line.
4. SOAP S/O/A in particular: if there's nothing real to say, write the honest "complete from bedside / nursing chart" line — never ship the bare scaffold.

Why this gate exists

A four-line repeat complaint of "this section is empty" means the previous fix is wrong, not under-applied. When the user names section A but the empties are in S and O (or vice versa), the symptom is "something is empty" — widen the scan to every block before responding. Char-count silently passes every skeleton; line-by-line scan does not.

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HTML EXPORT

• dir="rtl", David, Calibri, sans-serif, white-space: pre-wrap
• Each EMR section as <div class="section"> with copy button
• One copy button per Chameleon paste field (matches printed-order section list)
• English terms: <span dir="ltr">
• File: kabala_{last}_{first}_{DDMMYY}.html, shichrur_{last}_{first}_{DDMMYY}.html, or yeutz_{last}_{first}_{DDMMYY}.html

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QUALITY CHECKLIST

All notes

• No Unicode arrows (→ ← ↑ ↓), no **, no --, no >>>>
• In lab section: NO arrows at all — not even >. Prose only.
• Single > for med tapers in narrative (NOT in lab section)
• No >200/<50 — spelled out as מעל/מתחת
• No q8h/q6h — spelled out כל N שעות
• Labs RAW VALUES ONLY — no interpretation: no H/L suffix, no (מעל/מתחת לנורמה), no high/low words
• No trailing ? in prose — only (?) as plan uncertainty marker
• Drug recommendations as drug card (2-3 lines), no mixed English-Hebrew-English
• Dates as DD/MM/YY
• Lab values exact, not rounded

Discharge — printed-order discipline (verified 28/04/26)

• אבחנות פעילות = acute admit reason ONLY (chronic → ברקע)
• + blood transfusion w/ unit count if any units given during stay
• ניתוחים באשפוז = NGT / urinary cath / PEG events only (skip peripheral IV)
• אבחנות בעבר pre-populated — audit, don't auto-delete
• מחלה נוכחית = audited+fixed admission paragraph for retro paste-over (field APPENDS)
• הצגת החולה is a single line, not a paragraph
• תרופות בבית sits AFTER בדיקה גופנית (auto sidebar) — Title Case, don't force ALL-CAPS
• בדיקות עזר holds cultures FIRST, then imaging, then procedures — NEVER labs. NO doctor names, NO accession numbers, NO vial IDs/מספר בדיקה. Date OK.
• בדיקות מעבדה = categorized (ביוכימיה / מדדי דלקת / ספירת דם / גזים), prose trends ('בקבלה X, במהלך Y, בשחרור Z'), MAX 3 numbers/test, drop eGFR+BUN if Cr listed, correct total Ca for albumin same-day, RAW VALUES ONLY (no L/H, no normal-range parens, no interpretation)
• מהלך ודיון opens with patient summary template before any # header
• # headers are short and disease-focused
• # טיפול יעדי only if documented decision (not speculative)
• # תפקוד at end of מהלך ודיון
• NO bullet > 180 chars in המלצות בשחרור (Chameleon truncates) — split if needed
• המלצות בשחרור = DASH list (-), no boilerplate ("פנייה למיון/הבא סיכום")
• המשך טיפול תרופתי = DASH list (-), EMR auto-numbers
• For PEG patients: include Water per gastrostomy 400 ml X 3 / d לפי צורך
• Borderline home meds → keep on PRN with לפי החלטת רופא מטפל, never deprescribe in print
• Drug names in narrative (מחלה נוכחית / מהלך ודיון) = ALL-CAPS English
• NO glossary, NO תרופות באשפוז section, NO PT/OT/dietician prose blocks in body
• PT, OT, dietician referrals mentioned briefly in המלצות בשחרור only
• Completed ABX not in discharge Rx
• Attending cosignature; signature lines in correct order; Eias lic 000147224

Discharge — active diagnosis completeness check

• Type 2 MI surfaced if troponin elevated during septic shock?
• IDA / new anemia phenotype in active dx if workup pending or deferred?
• New HF phenotype (HFmrEF / HFpEF) in active dx with EF + date?
• PHT / RV dysfunction in active dx if echo found?
• Incidental CT findings (sinus opacification, lung nodules) in active dx if follow-up needed?
• Chronic respiratory failure / O2 dependence in background if applicable?

Discharge — geriatric red flags to verify

• Brotizolam/benzos/Z-drugs after delirium — justified or stopped?
• Apixaban dose meets reduction criteria (≥2 of 3)?
• Vitamin D status reassessed
• Mirtazapine dose reviewed
• Home prophylactic ABX — restart logic documented?
• Empiric ABX narrowed to culture sensitivities?

Ward admission notes

• Diagnoses in English; IDA/hypothyroid in background
• רקע רפואי present
• Meds in SZMC format
• Padua score; CHADS2/VASc if AF
• Problem-based # discussion
• Functional status one value per field
• תפקוד subsection uses 3-tier ADL grading (עצמאי / עזרה חלקית / עזרה מלאה) for each of: הלבשה, רחצה, אכילה, הכנת אוכל, ניידות, ניידות בכ"ג, מעברים, שליטה על שתן, שליטה על יציאה
• NO MRS scale in admission template — use plain Hebrew (סיעודי, מרותק למיטה) for narrative severity descriptors
• Geriatric analysis in chat only
• Trend data (multi-admission Hb, Plt, BP) flagged when diagnostic — not just point-in-time numbers

Rehab admission (קבלת שיקום)

• Header uses the NEW rehab אשפוז number, not the acute-stay number
• Inherits source-dept narrative in מחלה נוכחית — does not retake history; when asked "as if admitted to [surgical dept]", HPI = the ortho course (fall→fracture→fixation→post-op→transfer), NOT the at-home story
• Did NOT propagate the source's "no PMH" when the coded background contradicts it (coded list is often richer); discrepancy flagged
• On-arrival snapshot uses the admission-encounter bedside vitals, NOT the AZMA header; + 4-system exam + neuro if post-CVA/post-spine
• בדיקות עזר = dedicated section (ECG/CXR/CT/CTA/Doppler/ECHO, one line each, no specimen refs)
• Cross-checked the בדיקות עזר free-text panel for wrong-patient/template contamination — foreign values flagged + cleared, never pasted
• בדיקות מעבדה = dedicated section, raw values, prose trend, no specimen/accession IDs — filled, not blank
• תלונה עיקרית = transfer reason, one line
• אבחנות פעילות = ADMISSION FOR REHABILITATION + active acute only; surgery → ניתוחים בעבר; resolved/chronic → ברקע; dx pulled from the CODED list, not the prose
• תפקוד grid FILLED in full from PT/OT (9 ADL 3-tier + מגורים/עזרה/ניידות-aid/התמצאות/הזנה); floor/elevator reconciled across admission vs social-work (discharge-critical); room/bed resolved; no "confirm" placeholders in body
• דיון OPENS with the synthesis capsule (age + baseline + רקע כמפורט מעלה + ortho-for-surgery→transferred-for-rehab + pertinent on-arrival exam + pertinent latest imaging/labs) then כעת מציגה את הבעיות הבאות לדיון: + # list — NOT a bare # list; each # expands the reasoning (loading doses given, agent choice + why); no plan inside
• תוכנית = separate final paragraph, ONE line per item; includes drug-start/stop decisions with timing and an estimated suture/staple removal date by POD (hip = POD 10–14, computed from surgery date)
• Medication orders to give/enter output in the SAME turn — grouped קבוע/PRN/held; default = sending-dept AZMA active orders unless letter overrides; documented med recs implemented (add/reduce/stop/titrate)
• Terminology = real medical terms / inline English, not literal Hebrew calques (שבר פתולוגי not שבר שבריריות; GERD; kyphoplasty; normocytic; neurogenic claudication)
• Genuine unknowns / source contradictions live ONLY in the non-copy team-flags box
• Does NOT recreate PT/OT/dietitian intake content (those are separate authored notes)

Rehab daily rounds (ביקור רופא)

• All 5 SOAP headers underlined and present: S / O / A / P / תוכנית טיפול
• Triage: day-1 → FIRST-DAY | subsequent stable → STABLE | subsequent ≥2 triggers → COMPLEX
• FIRST-DAY: 3-4 line patient capsule in A (formula: age/marital/parents/living + רקע + בבסיס + acute event + day N post-event)
• FIRST-DAY: demographics cross-checked against admission הצגת החולה (marital, parent count, living situation, contact person)
• FIRST-DAY: indication-matched focused exam (CVA→neuro+gait, hip/knee→wound+per-limb, spine→wound+motor+sensation+sphincter, pre-cardiac→murmur+JVP+edema, ESKD→fistula)
• FIRST-DAY: source-dept clinical claims audited before propagating (Vit D level interpretation, "continue Aclasta" type recs, medication adequacy)
• FIRST-DAY: discharge constraints surfaced (lives alone? high floor? no elevator?) → social work day-1 if relevant
• STABLE: minimal A as 1-2 line synthesis; P often המשך שיקום
• COMPLEX: each A bullet starts with *[domain] - (אורתופדית / זיהומית / תפקודית / כלייתי / לבבי / לחץ דם / בצקת / נשימתי / נוירולוגית / כאב / שתן / מטבולית / פצע / עצירות / שינה / תזונתי / פסיכולוגית / עצמות)
• COMPLEX: P has explicit timing per action (היום / מחר בבוקר / יומיומית / לפני המנה הבאה)
• Labs in their own מעבדה: section after O (date-stamped), NOT in O; a decision-driving value may also be cited inline in the relevant A bullet
• Drug levels (Vanco, etc.) tracked when on those drugs — flag if missing
• Daily weight noted in P if on diuretics
• Dizziness / pre-syncope events get their own bullet, not buried in *תפקודית
• Pre-admission falls + in-rehab near-falls connected as a syndrome
• תוכנית טיפול goal concrete by indication (lazy מוקדם מדי only legitimate for CVA day 0-3 or post-team-meeting deferred)
• תוכנית טיפול goal updated post team-meeting — flag if frozen at "מוקדם מדי" past day 7
• No Beers/STOPP/START block — deprescribing decisions go inline in * bullets when actually changing a med
• No fresh history-taking — that belongs in the admission note
• CKD-MBD vs osteoporosis — do NOT recommend bisphosphonate in ESKD/HD without full workup + nephro/endo consult

Consults

• Scope correct — in-lane items specific, out-of-lane referred generally
• No jargon — no CFS, Beers, STOPP/START, ACB, BPSD, CAM, PAINAD, deprescribing, polypharmacy
• No proactive GOC unless asked or imminent EOL
• Drug recommendations as drug cards
• Hebrew accessible to non-geriatric reader

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REFERENCE PATTERNS (compact)

CHF triggers: א. קרדיאלי ב. וסקולרי ג. שינוי אורחות חיים ד. זיהומי — each with evidence + counter-argument.

LP: CT מוח ללא ממצא, ניקור מותני סטירילי, נוזל צלול, ל.פ. X ס"מ מים, Y מבחנות.

Culture results: סוג דגימה: [X] / חיידק: [X] / רגיש ל: [list] / עמיד ל: [list] / תאריך: DD/MM/YYYY

POCUS: בדיקת IVC, כ-X ס"מ, קריסה של כ-Y%.

Allergy: [Drug] - תגובה: [reaction] or [Drug] - תגובה: לא ידוע

Habits: מעשן: לא / שימוש באלכוהול: לא / שימוש בסמים: לא

ED discharge (no # headers): Style 1: במיון — then לסיכום —. Style 2: bare lines.

Departments: גריאטריה -מח / גריאטריה מוגבר / רפואה דחופה-מיון / רפואה פנימית / שיקום

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CHANGELOG

See CHANGELOG.md (sibling of this file) for full dev history. Not loaded at runtime.