Lesson L3-3 · authored fragments (docs/43)
Primary review content — the AI-avatar narration, in order.
Now the most important sticker on this list: "Hold for heart rate less than 60." The word HOLD is a hard stop. It means: before you give this dose, you check the pulse. If the pulse is 60 or higher, you give it. If the pulse is under 60 — say it reads 52 — you do NOT give it. You hold the dose, and you report it right away, the way your home tells you to. Here is the trap new MAPs fall into. They think "hold" is a suggestion — like, give it anyway and keep an eye on the resident. No. Hold means hold. A resident whose pulse is already under 60 can be harmed by that dose. That is the whole reason the sticker is there. And any time a sticker uses a word you don't know? Same rule as always. STOP. Don't guess. Ask your supervisor or call the pharmacy. The label is telling you something the doctor and the pharmacist decided together — you don't have to figure it out on your own.
Two last things that connect to what you already know. First — "Take whole." If a sticker says take whole, that is the crush rule you learned before. You do not crush it, and you do not split it. If your resident can't swallow it whole, you stop and call the prescriber for another form. Second — a special instruction can tighten your timing. Think about "take with food." If a dose has to go with a meal, then you can't just give it any time in the window — it is tied to when your resident eats. So a sticker can make Right Time narrower than the usual window. Read the sticker first, then plan the timing. The habit is simple: pick up the bottle, read the big label, then read every little sticker — and follow each one.
Let me show you the sticker that can hurt your resident. Every bottle you pick up has the big pharmacy label — your resident's name, the drug, the dose, the time. But look lower. See those little colored stickers? Those are warning labels. Here is what new folks get wrong: they treat them like reminders. They are not reminders. Each one is an order — the doctor and the pharmacist decided it together, and it is telling YOU how to give this dose safely. One of them says "Hold for heart rate less than 60." If you skip that sticker and give the dose to a resident whose pulse is 52, you can hurt them. That is not a paperwork slip. That is your resident in trouble. So today, we read the stickers.
Here is what the most common stickers tell you to do. Read each one like this — what it means, and what you do. "Take with food." This dose needs food in the stomach. You give it with a meal or a snack — not when the stomach is empty. "Take on an empty stomach." The opposite. You give this one when the stomach is empty — before a meal, with no food. "Avoid dairy" — sometimes it says "no dairy." Don't give this dose with milk, cheese, or yogurt. Give it with water instead. "Do not give if the client is having diarrhea." If your resident has diarrhea that day, you hold this dose and report it. You do not give it and hope for the best. Notice something — every one of these changes what you do at the cart. That is why they are orders, not suggestions. "With food" is not nurse stuff. It is your job.
25 of 25 critical claims are verified_by: null (Gate-2 SME sign-off pending → preview only, production-blocked under the Rule-3.6 waiver). · runtime budget: 7:00
# Concept mirror — MA.L3-3.A (Reading Warning / Special-Instruction Labels)
> **MIRROR / NOTES ONLY.** The authoritative concept entry is **docs/42 §E, `MA.L3-3.A`**
> (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.L3-3.A` |
| `competency_id` | `C-3.3` (⇄ `MA.L3-1.D` Right Time; ⇄ `MA.L3-2.C` crush rule / "take whole") |
| `lesson_ids` | `[L3-3]` + cross-cutting (supplemental labels appear on every route, not just oral) |
| `clinical_risk` | **High** → ≥90% KC mastery, spaced repetition (docs/42 §H). *Not* Critical: no 100%-gate, no force-fail, no SME-protected key |
| `medication_error_prevented` | Giving a dose under a condition the label forbids — e.g., a "hold for heart rate less than 60" med at pulse 52, a "with food" med on an empty stomach, a "no dairy" med with milk |
| `sme_status` (docs/42) | **not_started** — see Decision queue #0 (this bundle is authored even further ahead than the Rule-3.6 in_review waiver assumes) |
| `apd_traceability_status` | sourced — all administration-condition labels trace to [APD] Mod2 s62 / Mod3 s13 / ck Mod2 v4 Q14; two [Waiver360-added] instructional framings |
## Rule-3.6 author-ahead waiver (recorded 2026-07-05)
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_*`.
**Additional caveat for THIS concept:** docs/42 field 17 lists MA.L3-3.A as `sme_status: not_started`
(MA.L3-6.A was `in_review`). This bundle is therefore authored **one gate earlier** than the template
concept. The concept must be promoted `not_started → in_review → approved` before these fragments can
advance past draft. Flagged as Decision #0.
## Source ledger (projects into `payload_json.sources`)
- `curriculum_source`: "APD BMA Module 2 s62 (administration-condition labels) + Module 3 s13 (pay close attention to instructions); checkpoint Mod2 v4 Q14 (dairy)"
- `form_reference`: "— (label literacy is route-agnostic; no MAR form field is the source of truth here)"
| # | Claim | Tag | Source | verified_by |
|---|---|---|---|---|
| C1 | Supplemental/warning labels are prescriber+pharmacist **orders**, not optional suggestions — the MAP must find and follow each one | `[APD]` | Mod2 s62; Mod3 s13 | null |
| C2 | "Take with food" = give with food in the stomach (a meal/snack); "Take on an empty stomach" = give with no food | `[APD]` (labels verbatim) | Mod2 s62 — *exact hour windows NOT specified; no thresholds asserted* | null |
| C3 | "Hold for heart rate less than 60" = check the pulse; if under 60, do **not** give the dose | `[APD]` | Mod2 s62 | null |
| C4 | "Do not give if the client is having diarrhea" = hold the dose when the client has diarrhea | `[APD]` | Mod2 s62 | null |
| C5 | "Avoid dairy / no dairy" = don't give with milk/cheese/yogurt; give with water | `[APD]` | checkpoint Mod2 v4 Q14 (dairy) | null |
| C6 | "Take whole" = the do-not-crush rule (do not crush/split; escalate for another form) | `[APD]` (cross-cutting) | Mod2 s118 via MA.L3-2.C | null |
| C7 | A special instruction can **narrow the practical Right-Time window** (a with-food dose is tied to mealtime) | `[Waiver360-added]` | Instructional connection to Right Time; the 2-hour window itself is [APD] Mod1 s69 | null |
| C8 | A **held** dose (hold-for-pulse / diarrhea) must be **reported** so the nurse/prescriber can decide next steps | `[Waiver360-added]` | Procedural framing — the "report/notify" recipient is not APD-verbatim | null |
| C9 | Giving a dose under a forbidden condition can **harm the resident** (reduced efficacy/harm) | `[APD]` (error field) | docs/42 §E field 5 + Mod2 s62 — *specific clinical mechanism not asserted* | null |
## Patient-safety chain (owner directive — this is a patient-safety concept)
1. **Medication error prevented.** A MAP gives a dose under a condition the label forbids — most
dangerously, a resident whose pulse is **52** receives a med stickered **"Hold for heart rate less
than 60"**; also a "with food" med given on an empty stomach, or a "no dairy" med given with milk.
2. **Why staff make this mistake (the real reason).** A new MAP reads the *big* pharmacy label — name,
drug, dose, time — and treats the *little colored stickers* as reminders or "nurse stuff," because
nobody told them a sticker is a prescriber+pharmacist **order**. Under time pressure at the cart,
*holding* a dose feels like "not doing my job," so they give it and move on. The mistake is a mental
model ("stickers are optional"), not forgetfulness.
3. **How the lesson/transcript prevents it.** The narration reframes every sticker as an order the
doctor and pharmacist decided together, decodes each one into **"what it means / what you do,"** and
teaches that a **"hold" parameter is a hard stop** — check the pulse, and if it is under 60, do NOT
give it and report it. The "STOP, don't guess, ask" escalation covers any label word the MAP doesn't
know.
4. **How the simulator reinforces it.** In the MAR Simulator a med carries a **"take with food"** label;
giving it on an empty stomach is **flagged and coached** (High-risk flag, not a force-fail), and the
hold-for-pulse pattern makes the learner check the pulse before administering.
5. **How the KC verifies mastery.** **Q1** makes the learner match each sticker to its correct action
(the advisory-trap tile "give it and just watch them" is a wrong match for the hold label). **Q2**
puts them at the cart with a pulse of **52** and a "hold for HR < 60" sticker and passes **only** if
they hold the dose and report it — proving they treat a hold parameter as an order, not advice.
## Decision queue → owner / SME (Michele + Nicole)
0. **Concept status gate.** docs/42 lists MA.L3-3.A as `sme_status: not_started`. Promote to
`in_review` (then `approved` + Gate-2 sign-off) before any fragment here leaves draft. **This gates
the whole bundle.**
1. **C8 — held-dose reporting (`[Waiver360-added]`).** Narration and Q2 say a held dose must be
"reported right away, the way your home tells you." APD source states the *hold*; it does not name a
report recipient/timing. Confirm this framing is acceptable and, if APD/facility policy specifies a
recipient (nurse vs. prescriber vs. supervisor), supply it. Until then C8 is `verified_by: null` and
the exact recipient is **not** locked into the answer key.
2. **C7 — "labels can tighten the Right-Time window" (`[Waiver360-added]`).** Confirm this instructional
connection is acceptable as a bridge to MA.L3-1.D / the 2-hour window, or restrict L3-3 to label
*reading* only.
3. **Sticker set scope.** This bundle teaches ONLY the Mod2 s62 + Q14 administration-condition labels
(with food, empty stomach, hold-for-pulse, do-not-give-if-diarrhea, no dairy) plus the cross-cutting
"take whole." The **frozen legacy lesson** additionally taught **"MAY CAUSE DROWSINESS"** with a
"watch for the next hour or so" observation window — that sticker and its duration are **not in the
concept's APD source** (legacy TODO L33-R02) and were **deliberately excluded**. Confirm whether
MAY-CAUSE-DROWSINESS should be added to the concept (would need a source) or stay out.
4. **Sim binding.** The sim rule attaches a "take with food" label to a med in the MAR Simulator but the
concrete synthetic-client/med binding is unassigned (`[Needs Owner Review]`). SME to assign the
client + med so the sim scenario is concrete.
5. **Q1 exercise type.** `label_action_match` is a **proposed** (unregistered) exercise type — see
`exercise-specs/label_action_match.json`. Engineering/CMS decision: build it, or implement Q1 as a
configured mode of an existing matcher.
## Bundle contents
- Transcript blocks: `l33-warning-labels-hook`, `l33-warning-labels`, `l33-hold-parameters`, `l33-labels-and-timing`
*(docs/42 field 15 currently names only `l33-warning-labels`; this bundle proposes the 4-block
decomposition above — recommend docs/42 field 15 be updated on concept approval; see traceability gaps).*
- Knowledge checks: `KC-L3-3-A-Q1` (label_action_match), `KC-L3-3-A-Q2` (mcq4). Deferred variants:
`KC-L3-3-A-Q1B`, `KC-L3-3-A-Q2B`.
- Exercise spec (proposed): `label_action_match`.
- Sim rule: `mar-simulator--with-food-label-flag`.
- Storyboard frame referenced from docs/42: `V-L3-3-01` (proposed). Additional frames for the 4-block
decomposition are owned by the later lesson-storyboard aggregation step.
Match each warning label to the correct action at the med cart.
Why: Every sticker is an order that changes what you do at the cart: with food means give it with a meal or snack; empty stomach means give it before a meal with no food; hold for HR under 60 means check the pulse and hold if it is low; do-not-give-if-diarrhea means hold the dose. Each one has one right action.
Error prevented: Giving a dose under a condition the label forbids — a with-food med on an empty stomach, a no-dairy med with milk, or a hold-for-pulse med when the pulse is under 60.
Misconception: "Supplemental labels are optional / nurse stuff" and "a 'hold' parameter is advisory."
It's 8:00 AM. One of Rosa's morning pills has a sticker that says "Hold for heart rate less than 60." You check her pulse and it reads 52. What do you do?
Why: "Hold for heart rate less than 60" is an order. A pulse of 52 is under 60, so you hold the dose and report it right away. You do not give it.
Error prevented: Giving a hold-for-pulse medication to a resident whose pulse is under 60.
Misconception: "A 'hold' parameter is advisory" and "supplemental labels are optional / nurse stuff."
Entry: Learner reaches a med in the MAR Simulator that carries a 'take with food' supplemental label and prepares to administer it.
Mastery: ≥90% with spaced repetition (docs/42 §H). Flag-and-coach on the administration-condition miss; no force-fail, no 100% gate.
Shot: MS Michele at the med cart, group-home kitchen behind; brand bug top-right. Cut to insert B-roll: a single pharmacy bottle held up - the big pharmacy label on top, small colored supplemental stickers along the bottom, one reading 'Hold for heart rate less than 60'.
Camera: Open on eye-level medium shot; slow push-in on the hook line 'the sticker that can hurt your resident'; cut to a macro insert that racks focus from the big label down to the little colored stickers.
Avatar: Michele on-camera for the framing line; voiceover over the bottle B-roll for the 'they treat them like reminders - they are not' beat.
Visual: Establish the danger before any rule: the little sticker most people ignore is the one that can harm. Contrast the big pharmacy label (known) with the small supplemental stickers (overlooked).
Animation: The supplemental stickers along the bottle pulse once; the 'Hold for heart rate less than 60' sticker scales up; a pulse readout '52' briefly appears beside it to preview the hard-stop stakes (no client shown).
Infographic: Callout arrow from the big label to the small stickers with the caption 'orders, not reminders'; a red-outline highlight lands on 'Hold for heart rate less than 60'.
Shot: Full-screen animated sticker set: 'Take with food', 'Take on an empty stomach', 'Avoid dairy', 'Do not give if the client is having diarrhea'. Each sticker decodes into a two-line 'what it means / what you do' card.
Camera: No live camera; digital moves only - each sticker slides to center, expands, then settles into a stacked reference list.
Avatar: Voiceover; Michele off-screen.
Visual: The concept's core visual: a real label with its supplemental stickers highlighted and decoded. Each sticker reads as 'what it means / what you do' so the learner sees every sticker changes an action at the cart.
Animation: Each sticker expands into its 'what it means / what you do' card in sequence (docs/42 MA.L3-3.A field 11); a small hand/cart icon animates the action so the sticker is tied to a cart behavior, not a definition.
Infographic: Per-sticker two-column card: left 'What it means', right 'What you do'. 'With food' -> give with a meal or snack; 'Empty stomach' -> before a meal, no food; 'Avoid dairy' -> no milk/cheese/yogurt, give with water; 'Do not give if diarrhea' -> hold and report.
Shot: Tight on the 'Hold for heart rate less than 60' sticker; a pulse-check inset (radial dial + reading) rises beside it. Synthetic client 'Rosa' named only as an on-screen scenario tag, no face.
Camera: Macro hold on the sticker so the word HOLD reads clearly; a hard cut to the pulse dial as the reading lands on 52; no camera drift.
Avatar: Voiceover; slight lean-in energy on 'Hold means hold' (delivered by Michele off-screen).
Visual: The single most important safety beat: HOLD is a hard stop, not advice. Show the decision fork - pulse >=60 give / pulse <60 hold+report - so the 'give it and just watch them' trap is visibly the wrong branch.
Animation: The word HOLD stamps in; the pulse dial animates to 52; a red STOP ring closes around the dose; the advisory-trap tile greys out and is crossed off. A 'STOP. Don't guess. Ask.' chip fades in for unknown label words.
Infographic: Decision fork: pulse dial -> [>= 60: GREEN 'give it'] vs [< 60: RED 'do NOT give - hold and report']; a struck-through 'give it and just watch them' advisory-trap tile.
Shot: Split screen: left = a 'Take whole' sticker linking to the crush-rule icon (do-not-crush); right = a 'Take with food' sticker linking to a clock whose Right-Time window visibly narrows around a meal.
Camera: No live camera; a link-line draws left (take-whole -> crush rule) then right (with-food -> tighter clock window); settle on the closing habit loop.
Avatar: Voiceover.
Visual: Connect the new sticker skill to what the learner already owns: 'take whole' is the crush rule (cross-cutting, points to MA.L3-2.C, not re-taught here), and a special instruction can tighten the Right-Time window (bridge to MA.L3-1.D).
Animation: Crush-rule link-line draws to the MA.L3-2.C do-not-crush glyph; on the right the Right-Time band contracts to hug a meal icon (C7 [Waiver360-added] bridge); habit loop draws as a three-step cycle.
Infographic: Left: 'Take whole = do-not-crush - STOP and call for a safe form' (no recipient named). Right: a clock band that shrinks from the full window to a mealtime-tied window; caption 'the sticker can make Right Time narrower'. Closing habit chip: 'Big label -> every little sticker -> follow each one'.
Annotated pharmacy bottle + supplemental-sticker set (with food, empty stomach, avoid dairy, do-not-give-if-diarrhea), each sticker decoding into a 'what it means / what you do' card.
🖼 image prompt: Clean flat-vector pharmacy medication bottle, large primary Rx label on top, a row of small colored supplemental 'warning' stickers along the lower body reading 'Take with food', 'Take on an empty stomach', 'Avoid dairy', 'Do not give if client is having diarrhea'; each sticker paired with a two-column 'What it means / What you do' card; neutral clinical palette, high legibility, synthetic content only, no real client names, no logos, no APD/state seals. [APD] (labels: Mod2 s62; dairy: ck Mod2 v4 Q14).
🎬 video prompt: Sequential decode animation: each supplemental sticker slides to center and expands into its 'What it means / What you do' card, with a small cart/hand icon performing the action; stickers then stack into a reference list; no camera move; transparent background. [APD]
Hook insert: the big Rx label vs. the small overlooked supplemental stickers, with a red highlight landing on 'Hold for heart rate less than 60' and a brief '52' pulse preview.
🖼 image prompt: Macro flat-vector shot of a pharmacy bottle, focus racking from the large Rx label down to a small colored sticker reading 'Hold for heart rate less than 60', red highlight outline around that sticker, caption 'orders, not reminders'; neutral clinical palette; no client face; synthetic only. [APD] (Mod2 s62).
🎬 video prompt: Focus rack from big label to small stickers; the 'Hold for heart rate less than 60' sticker scales up; a pulse readout '52' fades in beside it and holds ~1s; no client shown; transparent background. [APD] (hold label Mod2 s62; the harm-at-pulse-52 stakes are the concept error field, no clinical mechanism asserted).
Hold-parameter hard-stop animation: 'Hold for heart rate less than 60' sticker + pulse dial animating to 52; decision fork give(>=60)/hold+report(<60); the 'give it and just watch them' advisory-trap tile crossed off.
🖼 image prompt: Flat-vector 'Hold for heart rate less than 60' sticker beside a radial pulse dial reading 52; a two-branch decision fork - green 'give it' for pulse 60+ and red 'do NOT give - hold and report' for under 60; a greyed, struck-through tile reading 'give it and just watch them'; clinical neutral palette; synthetic; no APD/state seal. [APD] (Mod2 s62). Report recipient NOT shown (C8 [Waiver360-added], TODO(source-L33-1)).
🎬 video prompt: 'HOLD' stamps in; pulse dial sweeps to 52; a red STOP ring closes around the dose; the advisory-trap tile greys and is crossed off; a 'STOP. Don't guess. Ask.' chip fades in; no camera move; transparent background. [APD] + [Waiver360-added] (do not name a report recipient - TODO(source-L33-1)).
Two connectors: 'Take whole' -> the crush-rule do-not-crush glyph (points to MA.L3-2.C, not re-taught); 'Take with food' -> a Right-Time clock band that narrows to a mealtime-tied window; closing habit loop.
🖼 image prompt: Split flat-vector diagram: left a 'Take whole' sticker linked to a do-not-crush icon with caption 'STOP - call for a safe form' (no recipient named); right a 'Take with food' sticker linked to a clock whose highlighted time band is narrow and hugs a meal icon, caption 'the sticker can make Right Time narrower'; a three-step habit loop 'Big label -> every little sticker -> follow each one'; clinical neutral palette; synthetic. [APD] take-whole (Mod2 s118, cross-cutting) + [Waiver360-added] Right-Time-tightening bridge (C7).
🎬 video prompt: Link-line draws from 'Take whole' to the do-not-crush glyph; on the right the Right-Time clock band contracts to hug the meal icon; the three-step habit loop draws as a cycle; no camera move; transparent background. [APD] + [Waiver360-added]. Escalation recipient NOT named (TODO(source-L32C-1)).
Shared 'STOP. Ask. Never guess.' escalation chip, reused across MA.L3-2.C / MA.L3-3.A / MA.L3-3.B.
🖼 image prompt: Minimal high-contrast reinforcement chip reading 'STOP. Ask. Never guess.'; warm neutral background; no faces, no logos, no APD/state seal; SVG-friendly. [Waiver360-added] shared escalation chip (grounded in the APD escalate-when-unsure / order-required principle; not APD-verbatim).
🎬 video prompt: Chip scales in with a soft bounce; 'STOP.' emphasized first, then 'Ask. Never guess.'; ~1.5s; transparent background. [Waiver360-added]
Target runtime: 7:00 · 5 chapters · not rendered (url: null)
Learner drags each prompt token (a warning-label sticker) onto exactly one action tile. Each prompt has exactly one correct action; some action tiles are distractors that no prompt should land on (e.g. an 'advisory' action for a hold label). Grading is per prompt: a prompt is correct only when placed on its correctActionId. Wrong placements fire the pair-specific rationale (keyed '<promptId>-to-<actionId>') and route to remediation.