Lesson L3-2 · authored fragments (docs/43)
Primary review content — the AI-avatar narration, in order.
Okay — now the pills that are NOT just "swallow it whole." On your shift you'll see a few special forms, and each one has its own rule. Get the rule wrong and your resident can end up with too much, too little, or none of the medicine at all. First, scored tablets. A scored tablet has a line across the middle. That line is NOT your permission to cut it. You only split a tablet when the ORDER says to give half — never just because it looks splittable. If the order says give one whole tablet, you give it whole, line or no line. Next, chewables. A chewable has to be chewed before it's swallowed — not gulped down whole. And the flip side matters just as much: if it isn't a chewable, don't let your resident chew it. Now the two that trip people up: sublingual and buccal. A sublingual tablet goes UNDER the tongue. A buccal tablet goes between the gum and the cheek — the cheek pocket. Both of them stay right where you put them and melt in place. Don't let your resident chew them, swallow them, or drink anything until the medicine is absorbed — one sip of water too early washes it away before it can work. And give these two LAST, after the other oral meds. Watch for the tablet to dissolve — that's your cue it's on its way. Dissolved is what you can see; absorbed is the finish line.
16 of 16 critical claims are verified_by: null (Gate-2 SME sign-off pending → preview only, production-blocked under the Rule-3.6 waiver). · runtime budget: 12:00
# Concept mirror — MA.L3-2.B (Scored / Chewable / Sublingual / Buccal)
> **MIRROR / NOTES ONLY.** The authoritative concept entry is **docs/42 §E, `MA.L3-2.B`**
> (Instructional Domain Model). This file is the local traceability ledger + decision queue for the
> derived-asset bundle; if it ever disagrees with docs/42, **docs/42 wins** (docs/43 §22 authority flow).
| Field | Value |
|---|---|
| `concept_id` | `MA.L3-2.B` |
| `competency_id` | `C-3.2` |
| `lesson_ids` | `[L3-2]` |
| `clinical_risk` | **High** (docs/42 field 6 "Moderate→High"; §H places it in **High ≥90%, spaced repetition**) → ≥90% KC mastery, spaced re-surfacing; **not** 100%-gating, **not** sim force-fail, KC keys **not** SME-protected (contrast: the crush rule MA.L3-2.C is the Critical/100%-gating concept in this lesson) |
| `medication_error_prevented` | A special-form tablet mishandled so the dose is reduced or wrong — a sublingual/buccal swallowed whole or washed down with a drink before it can absorb, or a scored tablet split without an order |
| `sme_status` | `in_review` |
| `apd_traceability_status` | sourced — all four form rules trace to `[APD]` Mod2 s30/s59/s68; one `[Waiver360-added]` framing ("dissolved = visible cue / absorbed = endpoint"); one `[Needs Owner Review]` item deliberately excluded from all learner-facing copy (pill-splitter technique) |
## Rule-3.6 author-ahead waiver (recorded 2026-07-05)
The concept is `in_review`, not `approved`. Per docs/42 §I.1 / docs/43 §4, this bundle is authored
**ahead of concept approval under a Rule-3.6 waiver** as part of the Oral Route reference build.
Consequence: **every fragment in this bundle is `sme_status: "draft"`, preview-flag only, and
production-publish-blocked** until (a) the concept reaches `approved` and (b) a Gate-2 SME sign-off is
recorded in `content_revisions.sme_signoff_*`.
## Source ledger (projects into `payload_json.sources`)
- `curriculum_source`: "APD BMA Module 2 (oral forms & special-form handling — slides 30, 59, 68); checkpoints Mod2 v2 Q24 (sublingual), Q30 (Lasix ½)"
- `form_reference`: "APD Form 65G-7.008 A (MAR — charting the sublingual dose)"
| # | Claim | Tag | Source | verified_by |
|---|---|---|---|---|
| C1 | A scored tablet is split (to give ½) **only with a prescriber order**; a score line alone does not authorize splitting — if the order says give one whole tablet, give it whole | `[APD]` | Mod2 s30; ck Mod2 v2 Q30 (Lasix ½) | null |
| C2 | Chewable tablets **must be chewed** before swallowing; a tablet that is **not** a chewable must **not** be chewed | `[APD]` | Mod2 s59 | null |
| C3 | A **sublingual** tablet goes **under the tongue**; a **buccal** tablet goes **between the gum and cheek** (the cheek pocket) | `[APD]` | Mod2 s68; ck Mod2 v2 Q24 (sublingual) | null |
| C4 | Sublingual/buccal tablets **dissolve/absorb in place** — not chewed, not swallowed whole — and the client **drinks nothing until the medication is absorbed** | `[APD]` | Mod2 s68 | null |
| C5 | Sublingual/buccal tablets are **given after (last, following) the other oral medications** | `[APD]` | Mod2 s68 | null |
| C6 | "Dissolved" is taught as the **visible cue** and "absorbed" as the **endpoint** (a DSP can *see* dissolution, not absorption) | `[Waiver360-added]` | Instructional framing of APD's "absorbed" endpoint; Mod2 s68 gives no time range (legacy SRC-L32-3 resolved 2026-07-02) | null |
| C7 | Use a **pill splitter, not fingers**, for an even split | `[Needs Owner Review]` | Legacy SRC-L32-2 (unresolved). **NOT in the docs/42 concept sources.** Deliberately **excluded** from narration, KC answer keys, and sim copy per docs/43 §15 until an SME confirms APD's splitting-technique guidance | null |
## Patient-safety chain (owner directive — this is a patient-safety concept)
1. **Medication error prevented:** A special-form tablet that never delivers its dose. A sublingual
or buccal tablet swallowed whole (or washed down with a sip of water before it absorbs) means the
resident gets little or none of the medicine — a silent under-dose that looks, on the MAR, like a
completed dose. And a scored tablet split without an order becomes a wrong (usually half) dose.
2. **Why staff make this mistake (the real-world reason):** These tablets *look like ordinary pills*.
On a busy med pass the reflex is "hand it over, hand a cup of water, move to the next resident."
That reflex is exactly wrong for sublingual/buccal — the water and the swallow are what defeat the
dose. Buccal is worse: most new MAPs have never heard of it, so it isn't even in their mental model
to slow down for. And a score line *feels* like built-in permission to halve a tablet ("it's made
to split, right?"), so splitting feels helpful, not like a scope violation.
3. **How the lesson/transcript prevents it:** The `l32-scored-and-special-tablets` block gives each
form one plain rule and anchors it to the resident — "split only with an order," "chewables get
chewed," sublingual = under the tongue, buccal = between gum and cheek, both melt in place, **no
drink until absorbed**, and **give these two last**. It names buccal explicitly so it enters the
MAP's model, and it teaches "dissolved is what you can see; absorbed is the finish line."
4. **How the simulator reinforces it:** The Don Montana MAR Simulator sublingual micro-step (proposed;
requires a synthetic SL dose — see Decision queue #3) **flags** charting the dose before it has
dissolved, giving a drink too early, or giving it before the other oral meds — coaching the learner
back to "watch it dissolve first, chart after." Because the concept is High (not Critical) this is a
**coaching flag, not a force-fail**.
5. **How the KC verifies mastery:** `KC-L3-2-B-Q1` makes the learner pick the correct sublingual
handling (given last, dissolve in place, no drink until absorbed) and includes a **buccal
placement distractor distinct from sublingual**, so choosing right proves they can tell the two
apart. `KC-L3-2-B-Q2` verifies "a score line is not permission to split" against the split-only-
with-an-order rule.
## Decision queue → owner / SME (Michele + Nicole)
1. **Pill-splitter technique (C7) — excluded pending SME.** docs/42's concept sources say only "split
scored **only with an order**." The legacy "use a splitter, not your fingers, for an even split"
technique (SRC-L32-2) is **not** in the concept and is `[Needs Owner Review]`; per docs/43 §15 it is
kept out of all narration/KC keys/sim copy. SME to confirm APD's splitting-technique guidance, then
it can be added (as `[APD]` or an explicit `[Waiver360-added]` best-practice badge) — or dropped.
2. **Confirm C6 framing** — is "dissolved = visible cue / absorbed = endpoint" acceptable as a
`[Waiver360-added]` scaffold of APD's "absorbed" endpoint (Mod2 s68, no time range; SRC-L32-3
resolved 2026-07-02)? It stays `verified_by: null` until confirmed.
3. **Sublingual sim micro-step needs a scenario med.** The Don Montana scenario
(`content/sim-scenarios/don-montana.json`) currently carries **no sublingual medication** — only
oral Diltiazem ER and the inhaled Spiriva/Albuterol. The concept's "charting a sublingual before
dissolution → flagged" opportunity therefore requires a **synthetic sublingual dose** to be added
to a scenario. Owner/SME to approve: which scenario, and a synthetic SL med (no real drug name
until sourced, to avoid a drug-specific claim).
4. **Chewable coverage.** "Chewables must be chewed" (C2) is currently verified only as a **distractor**
inside `KC-L3-2-B-Q2`, not as a dedicated item. Confirm this is sufficient, or approve a dedicated
chewable KC at production.
5. **Buccal copy** (added owner-approved 2026-07-05, docs/42 §I.3.2) — confirm the placement/handling
wording reads correctly for SME: between gum and cheek, dissolve in place, no chew, no drink until
absorbed, given last.
## Bundle contents (this concept)
- `blocks/l32-scored-and-special-tablets.json` — the single transcript block (covers all four forms)
- `knowledge-checks/KC-L3-2-B-Q1.json` — sublingual/buccal handling MCQ (buccal distractor)
- `knowledge-checks/KC-L3-2-B-Q2.json` — scored "not permission to split" MCQ
- `sim-rules/don-montana--sublingual-dissolve-flag.json` — coaching-flag gate (proposed SL micro-step)
- Storyboard frames referenced (aggregator assembles the storyboard): `V-L3-2-02`, `V-L3-2-03`
- **No exercise-spec** — KCs use the base `mcq4` type; no new registry exercise type is introduced.
- **Deferred remediation variants** (owner decision — deferred until the full route is done):
`KC-L3-2-B-Q1B`, `KC-L3-2-B-Q2B`.
Ms. Reeves has three morning medications, and one of them is a sublingual tablet. What is the correct way to give the sublingual tablet?
Why: A sublingual tablet goes under the tongue and dissolves in place. You give it last, after the other oral meds, and let nothing wash it away — no drink until it has absorbed. That is how the full dose actually gets in.
Error prevented: A sublingual/buccal dose swallowed, washed down, or given in the wrong placement so it never absorbs — a silent under-dose that reads on the MAR as a completed dose.
Misconception: "Sublingual can be swallowed (or washed down) to save time" and the buccal-vs-sublingual placement mix-up.
The MAR lists a scored tablet — it has a line across the middle — and the order says to give one whole tablet. What do you do?
Why: A score line only means the tablet CAN be split cleanly — it is not permission to split it. You split a tablet only when the order says to give half. This order says one whole tablet, so you give it whole.
Error prevented: A scored tablet split without an order — a wrong (usually half) dose — and chewing a tablet that is not meant to be chewed.
Misconception: "Any scored tablet can be split at will" (and over-generalizing chewing to non-chewables).
Entry: Learner reaches a med pass that includes a sublingual dose (synthetic; to be added). The learner must place it under the tongue and let it dissolve before charting.
Mastery: >=90% with spaced repetition (docs/42 §H); coaching-flag gate, not a 100% force-fail.
Shot: Tight on a scored tablet and a chewable tablet side by side; a 2x2 'where it goes / what to watch' grid begins to build.
Camera: Macro hold on the scored tablet's score line; no camera move so the line reads clearly; ease into the top row of the 2x2 grid.
Avatar: Voiceover; Michele off-screen.
Visual: First half of the 2x2 'where it goes / what to watch' - scored (a line is not permission to split; split only with an order) and chewable (must be chewed).
Animation: A score line is highlighted, then a dimmed 'X' rejects an unordered split; the chewable tablet animates a chew cue.
Infographic: 2x2 grid, top row filled: 'Scored - split ONLY with an order' and 'Chewable - must be chewed'; caption 'a line is not permission to split'.
Shot: Cutaway mouth diagram showing under-the-tongue (sublingual) and gum-and-cheek (buccal) placement; bottom row of the 2x2 grid fills.
Camera: Digital zoom to the placement diagram; hold steady on the dissolution timer.
Avatar: Voiceover.
Visual: Second half of the 2x2 - sublingual (under the tongue) vs. buccal (between gum and cheek), both distinct placements; dissolve in place, no chew, no drink until absorbed, given last.
Animation: Sublingual tablet dissolves on a timer (visible cue = dissolved; endpoint = absorbed); buccal tablet tucks into the cheek pocket; a 'given last' chip slides to the end of the med-pass order.
Infographic: 2x2 grid bottom row: 'Sublingual - under the tongue' and 'Buccal - between gum and cheek'; shared chips 'dissolve, don't chew', 'no drink until absorbed', 'give last'.
Scored + chewable tablets with the top row of the 2x2 'where it goes / what to watch' grid; 'a line is not permission to split'.
🖼 image prompt: Flat-vector close-up of a scored (grooved) tablet beside a chewable tablet, with a two-cell grid reading 'Scored - split ONLY with an order' and 'Chewable - must be chewed', and a caption 'a line is not permission to split'; neutral clinical palette; synthetic props only. [APD] Mod2 s30, s59.
🎬 video prompt: A score line highlights; a dimmed red X rejects an unordered split; the chewable tablet shows a gentle chew cue; grid cells fill in; no camera move. [APD]
Sublingual vs. buccal placement cutaway with a dissolution timer; bottom row of the 2x2 grid.
🖼 image prompt: Flat-vector cutaway mouth diagram showing one tablet under the tongue (labeled 'Sublingual') and one between the gum and cheek (labeled 'Buccal'), with shared chips 'dissolve, don't chew', 'no drink until absorbed', 'give last'; neutral clinical palette; no faces beyond a simple anatomical cutaway. [APD] Mod2 s68.
🎬 video prompt: The sublingual tablet dissolves on a visible timer (cue = dissolved, endpoint = absorbed); the buccal tablet tucks into the cheek pocket; a 'given last' chip slides to the end of a med-pass order strip; no time-in-seconds asserted. [APD]+[Waiver360-added] (dissolved=cue/absorbed=endpoint framing is Waiver360-added)
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