Sophia

Resident record

One secure record per resident: profile, care level, diagnoses, contacts, financials and documents.

FaceSheet

The one page a nurse hands to a paramedic, the whole chart summarized, on screen and as a PDF.

Safety flags

Code status, presence and the health attributes that change what staff do at the cart.

Vitals

Every reading in one feed, with the latest value tracked per metric.

Care plan (Assessment and Service Plan)

A signable care plan that pre-fills from the chart and carries its own signing team.

Physician orders and plan of care

The Physician Order for Assisted Living and the Physician Plan of Care, print to fax, or send to the physician to sign.

Incident reports

What happened, when, and who signed off on it.

Activities and Daily Roll

The activity calendar, and exception-based attendance on a monthly grid.

Notes Center

One notes record across residents, leads, tasks and incidents.

Therapies EMR

Per-resident PT, OT and ST charting, track, episode, note, SOAP, signed and locked.

Therapy supervision and units

The every-tenth-visit supervision rule, without spending a payer visit on it.

Whether a note is the shared supervisory visit is derived from its position since the last supervisory event, so it stays an ordinary treatment note and no visit is consumed against a payer cap. The assistant is blocked from opening the next visit until the co-sign carries the therapist's supervisory assessment and a therapist-performed unit. Units come from the CMS 8-minute table and cap at four, except on the shared visit where two clinicians' minutes combine. Every charge line stamps the clinician who performed it, so a co-signed visit splits between assistant and therapist correctly. Signing a billable visit with no interventions is refused.

eMAR orders

One order model for medications, treatments, vital signs and information, routine or PRN.

An order carries its diagnosis, prescriber and pharmacy as real links rather than typed names, plus its controlled schedule, a sliding scale, the vitals that must be captured at administration, and a body site. Schedule times are facility-local, with daily, weekly, every-N-weeks, interval, monthly-date and monthly-nth-weekday recurrence. A prescriber picked from the directory must be one of that resident's own linked providers. Review sign-off is voided by a clinical edit, so a reviewed order is a reviewed version. Names, strengths, frequencies and routes autocomplete from what the building already uses and from the national drug vocabulary, and controlled status is looked up rather than remembered.

PRN dose bounds

PRN orders carry a minimum interval and a maximum per 24 hours as structured numbers.

Crossing either raises a warning the nurse overrides with a note, not a silent allow, and not a hard block that teaches people to work around it. A required PRN reason and the dose range are enforced on the server. Last-given and 24-hour totals aggregate across the whole supersede chain by normalized drug name, so re-writing an order does not reset the count.

Discontinue and replace

A dose change writes a new order that supersedes the old one, and the chain stays one clinical story.

Totals, last-given and PRN limits read across the chain instead of starting over. The discontinued order stays in the record, clipped at its discontinue date.

Occurrence expansion

One shared function decides what is due, and every surface uses it.

The pass screen, the MAR grid, the printed MAR and the missed-dose job all call the same expansion, with time-zone maths that survives a daylight-saving change. Occurrences clip to the order's start, end and discontinue dates. Legacy free-text frequencies are parsed into schedule rows, and a low-confidence parse becomes a loud needs-schedule card on the pass rather than an order that quietly never comes due.

Med pass

The cart screen: who is due, tap to give, exception with a reason, record the round.

MAR grid and printed packets

The month on one grid, and the paper the chart and the ambulance need.

Amend and void

Charting corrections that leave the record honest.

An amend fixes a row in place, a job-written missed dose becomes a late-charted give, and adjusts quantity on hand by the difference. A void says the record should never have existed: the row is kept for audit, dropped from the MAR, the PRN maths and the pass, and the slot reopens, because the uniqueness index only counts rows that are not voided. Super-admin only and audited, and every wall-clock field on the screen is read in the facility's time zone rather than the device's.

Self-administration

Two modes for a resident who keeps one of their medications, and one for a resident who keeps all of them.

Per order: self-administers, which takes it off the pass, the roster, missed-dose detection and the refill queue; or self-administers observed, which keeps it on the pass with a badge so staff witness and chart each dose without needing an exception reason. Per resident, self med pass excludes them from the roster entirely. Either way the order list, the MAR and the 911 packet stay authoritative, and the printed MAR marks the order so blank columns read as deliberate.

Order review queue

New, unreviewed and needs-schedule orders in one worklist.

Quantity on hand

The administration itself decrements the count.

A given, self-administered or wasted dose adjusts on-hand inside the same write that records it, and a supply-event ledger keeps every receipt, short shipment, count set and adjustment with the resulting count. Nothing depends on somebody remembering to run a count.

Refill queue

Grouped by how the refill actually happens.

Every order carries its refill method, pharmacy auto, call the pharmacy, an order from the physician without a visit, or one that needs a visit, and the worklist is grouped that way, with the visit path linking straight to that resident's appointments. A full receipt clears the request and sets the next refill date; a short one keeps it open. Days of supply project from the schedule and the count on hand, so a run-out is a date on a worklist instead of a Sunday phone call.

Receiving, packing slips and scan-check

Upload the pharmacy slip, review it, save once.

Extraction runs on the device, the PDF text layer for digital slips, OCR in the browser for scans and photos, so the slip itself never crosses the server boundary and only structured lines do. One saved parsing template per pharmacy format, created by a wizard that picks the Rx column by counting how many of its values match active order numbers. Review shows matched lines with drug-stem warnings, unmatched lines with candidate pickers, and a chase list, then prefills the receive worksheet, the delivery is still recorded by a person. A wedge scanner checks the physical tote against the worksheet by Rx number.

Physician portal

A physician signs orders and plans of care from their own office.

Signature requests arrive for plans of care, assisted-living orders and therapy evaluations, with batch signing for a stack of them. A physician or PA row in the provider directory is what gets the login, and the login's lifecycle is authorized on the linked provider's facility rather than on an organization field that legacy rows never had.

Med Pass Report

How the pass actually went: given, refused, held, not available and missed, one row per resident.

Supply Forecast

Days of supply projected from the schedule and the count on hand, with an act-by date.

Provider Visit Report

Visits across every provider type, with the resident detail behind each one.

Therapist Payroll

Semi-monthly per-unit payroll, itemised by therapist.

Lines attribute to the clinician who performed the unit, so a co-signed shared visit splits pay between assistant and therapist. A rate can default per therapist and be overridden per intervention code. A line with no rate is flagged and excluded from the total, never guessed. Each selected therapist can be emailed their own pay stub carrying only their own lines, and visits with no charges surface as their own amber table.

Therapy Visits

One row per visit with units, intervention codes and who performed them.