Care plans & problem list

Chronic-disease management with auto-flip on matching lab results. Lives inside any patient chart under the Care plans tab.

Problem list with decay signal

The Problem List shows active conditions per patient. Decay signal flags any active condition untouched (no encounter / lab / medication change) > 180 days. Direct attack on problem-list rot — the #1 root cause of stale problem lists in primary care.

Scribe proposes adds / dismisses based on what the provider said in the visit; the provider accepts before they hit the chart.

Care plans

A care plan groups Goals + Activities under a single condition (e.g., “Type 2 Diabetes management”). Goals carry target values (“A1C < 7.0 by 2026-09-01”). Activities are the recurring orders, education tasks, and follow-up appointments that move the patient toward the goal.

Chronic-disease auto-flip

When an ingested result matches a Goal’s target predicate (A1C < 7.0, BP < 140/90, etc.), the system auto-advances that Goal from in-progress → achieved. Provider sees a notification in the inbox. Manual revert is one click if the value was a fluke.

Auto-flip rules live in care_plan_triggers — admin-configurable per condition. Default rules cover HbA1c, BP, LDL, A1c follow-up intervals, and the common preventive-care care-gaps (annual physical, mammogram, colonoscopy, A1C-quarterly).

Behavioral-health care plans

Same structure with mental-health-specific Goals (PHQ-9 reduction, GAD-7 reduction, session attendance). PHQ-9 / GAD-7 forms are captured during intake and tracked over time.

Education library

Activities can attach patient-education resources from the library. Default library ships with US Core education materials; admin can add tenant-specific PDFs / videos.