Lesson L3-6 · authored fragments (docs/43)
Primary review content — the AI-avatar narration, in order.
The second place is the BACK of the MAR. Find the comments section and start a new row. Write five things. One — the date: 1/9. Two — the time: 8 AM. Three — the medication: Spiriva. Four — the reason, in Don's own words. Don said, "I'm tired of it." Write that, in quotes, exactly the way he said it — not your version of it. Five — your initials: M.D. Date, time, medication, reason, initials. Five things, every refusal.
A few quick questions. What if Don changes his mind ten minutes later and takes it? You still document the refusal at 8 AM. Then you document the dose he actually took, separately, at the time he took it. What if you're rushing to the next client? Make the time. An undocumented refusal counts the same as a missed dose when someone audits the record — and you will not remember at the end of your shift exactly what Don said. Write it now, while it's fresh. Front of the MAR. Back of the MAR. Both. Every time.
The first place is the FRONT of the MAR. Find the cell for the right day and time — January 9th, 8 AM, on the Spiriva row. Do NOT put your normal initials there. Plain initials mean the dose was given. Instead, use your refusal symbol: the same initials from the signature legend at the bottom of the MAR, with a circle around them. If your legend initials are M.D., your refusal mark is M.D. with a circle around it. That one mark tells the next MAP, your supervisor, and any inspector the same thing at a glance — this dose was refused. Not given. Not skipped. Not missed.
It's 8 in the morning. You bring Don his Spiriva. He looks at it and says, "I'm tired of it." You can't make him take it. So what do you write down — and where? Here's the rule that carries this whole lesson: a refusal is not a blank. It's not a skip. It's something you write down, in two places, every single time.
Why do the exact words matter so much? Because "tired of it" is different from "it makes me dizzy," which is different from "I'm too sick to sit up." What you write down can change what the prescriber does next. The reason is not optional. The quotation marks are not optional. You are the person who heard it — so you are the person who writes it down, in the client's own words.
19 of 19 critical claims are verified_by: null (Gate-2 SME sign-off pending → preview only, production-blocked under the Rule-3.6 waiver). · runtime budget: 4:00
# Concept mirror — MA.L3-6.A (Refusal: Front + Back, Every Time) > **MIRROR / NOTES ONLY.** The authoritative concept entry is **docs/42 §E, `MA.L3-6.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.L3-6.A` | | `competency_id` | `C-3.6` (⇄ `C-2.8`, `MA.L3-1.F`) | | `lesson_ids` | `[L3-6]` + cross-cutting (documented refusal recurs on every route) | | `clinical_risk` | **Critical** → 100% KC mastery, sim force-fail, SME-protected KC keys | | `medication_error_prevented` | A refusal left undocumented, or documented without a back-of-MAR reason | | `sme_status` | `in_review` | | `apd_traceability_status` | sourced — one open anchor (`TODO(source-L36-1)`) + two `[Waiver360-added]` | ## 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 the Oral Route reference implementation. 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 1 (immediate documentation) + APD MAR practical exam (Don Montana, River Short)" - `form_reference`: "APD Form 65G-7.008 A (MAR)" | # | Claim | Tag | Source | verified_by | |---|---|---|---|---| | C1 | A refusal is documented as a refusal — never left blank or charted as a missed/skipped dose | `[APD]` | MAR-DM 2b; MAR-RS 2c | null | | C2 | Front-of-MAR refusal mark = signature-legend initials rendered as the refusal symbol (**circled initials**) | `[APD]` | MAR-DM 2b answer key — **`TODO(source-L36-1)`** | null | | C3 | A refusal requires a back-of-MAR comment recording the reason | `[APD]` | MAR-DM 2b; MAR-RS 2c | null | | C4 | Documentation happens immediately after the refusal, not at end of shift | `[APD]` | Module 1 s71 (⇄ MA.L3-1.F) | null | | C5 | The back-of-MAR comment is a five-element format: date · time · medication · reason in client's own words (quoted) · initials | `[Waiver360-added]` | Instructional decomposition of C3 — not an APD-stated five-part format | null | | C6 | An undocumented refusal counts the same as a missed/unaccounted dose in an audit | `[Waiver360-added]` | Defensible audit-consequence framing — not APD-verbatim | null | ## Decision queue → owner / SME (Michele + Nicole) 1. **`TODO(source-L36-1)` — confirm the exact front-of-MAR refusal mark.** Bundle uses *circled legend initials* (from the existing L3-6 lesson + MAR-DM 2b). SME to confirm the precise APD convention (circle vs. other legend mark) before this concept can move `in_review → approved`. Until then, C2 is `verified_by: null` and the bundle stays preview-only. **This is the one item that gates the whole bundle to production.** 2. **Confirm C5 framing** — is the five-element back-of-MAR format acceptable as `[Waiver360-added]` scaffolding of the APD "record the reason" requirement, or does APD specify required fields? 3. **Confirm C6 framing** — "undocumented refusal = missed dose in an audit" acceptable as `[Waiver360-added]`? ## Bundle manifest → `../MA.L3-6.A.manifest.json` · human index → `../MA.L3-6.A.README.md`
Don refused his 8:00 AM Spiriva on January 9, saying "I'm tired of it." Drag the correct symbol into the correct cell on the MAR.
Why: Circled legend initials are the refusal symbol. The next MAP and any inspector see immediately that the dose was refused — not given, not skipped, not missed.
Error prevented: A refusal recorded as a given dose (falsified MAR) or as a blank/missed dose (unaccounted dose in an audit).
Misconception: "A refusal is a skip/missed dose" and "plain initials go in the cell."
River Short refused her 7:00 PM Metformin on January 12, saying "My stomach hurts." Drag the refusal symbol into the correct cell on the MAR.
Why: Same rule, different client, med, and time: circled legend initials mark the refusal on the front of the MAR.
Error prevented: Refusal recorded as a given/missed dose on a second, unfamiliar client.
Misconception: That the refusal mark is scenario-specific rather than a fixed convention.
You marked the refusal on the front of the MAR. Now type the back-of-MAR comment. Don refused his 8:00 AM Spiriva on January 9, saying "I'm tired of it." Your legend initials are M.D.
Why: Date, time, medication, the client's own words in quotes, and your initials — that's a complete refusal comment.
Error prevented: A refusal documented without a usable reason — stripping the prescriber of the information needed to decide what happens next.
Misconception: "Paraphrasing the reason is good enough" and "the reason is optional."
The back-of-MAR comment row already has the medication (Spiriva) and your initials (M.D.) filled in. Type the remaining three elements so the row is complete: date, time, and reason. Don refused his 8:00 AM Spiriva on January 9, saying "I'm tired of it."
Why: With the medication and initials given, the three you supply — date, time, and the quoted reason — finish a complete refusal comment.
Error prevented: A refusal comment that omits the reason or the timing after the learner has already shown they can name the med.
Misconception: That the hardest part of the comment is remembering all five fields, when the real gap is usually the quoted reason.
Entry: Learner reaches the 1/9 8:00 AM Spiriva pass in the Don Montana MAR Simulator; the client declines the dose ('I'm tired of it').
Mastery: 100% — force-fail on the refusal gate; no partial completion.
Force-fail: FORCE-FAIL. The scenario cannot complete until the refusal is documented correctly on both front and back. The sim does not silently fail: it surfaces the same compassionate-framing modal as the KC, with a direct link to the L3-6 re-anchor clip and a 'Try again' CTA.
Shot: MS Michele at med cart, group-home kitchen behind; brand bug top-right. Cut to B-roll: inhaler on cart, MAR with Don Montana name visible.
Camera: Open on eye-level medium shot; slow push-in during hook line; cut to insert B-roll of the inhaler + a speech-bubble caption card.
Avatar: Michele on-camera for the framing line; voiceover over the B-roll for the 'I'm tired of it' beat.
Visual: Establish the real refusal moment before any rule; the empty 8 AM cell is the unanswered question.
Animation: Caption card types in; empty 1/9 8 AM Spiriva cell pulses once.
Infographic: Speech-bubble caption card: "I'm tired of it." with quotation marks emphasized.
Shot: Full-screen animated MAR front; Spiriva row + 1/9 8 AM cell zoomed.
Camera: Digital zoom to the target cell; hold steady while narration names day/time/row.
Avatar: Voiceover; Michele off-screen.
Visual: Anchor the exact cell before introducing the mark; contrast plain vs. refusal initials.
Animation: Empty cell pulses; plain 'M.D.' appears then is rejected (dim) to teach the contrast.
Infographic: Callout label 'REFUSED' near the cell once the mark lands.
Shot: Tight on the 1/9 8 AM cell.
Camera: Macro hold on the cell; no camera move so the mark reads clearly.
Avatar: Voiceover.
Visual: The circled-initials mark is the single most important visual in the lesson.
Animation: SVG path draws a circle around 'M.D.' (~0.6s), then a soft REFUSED stamp.
Infographic: Callout: 'REFUSED - circled legend initials'.
Shot: Pan down to the signature legend at the bottom of the MAR.
Camera: Vertical pan from cell to legend; highlight 'M.D.' row.
Avatar: Voiceover.
Visual: Prove the mark is not invented — it comes from the legend the MAP already signed.
Animation: Legend 'M.D.' highlights; a link line connects it up to the circled cell mark.
Infographic: Callout: 'Use your legend initials'.
Shot: Flip animation to the back-of-MAR Comments table; blank row highlighted.
Camera: Card-flip transition front->back; settle on the empty comment row.
Avatar: Voiceover counting the five elements.
Visual: Make the five-element format concrete by building the row live.
Animation: Each element types into the row as it is named; quotation marks on the reason emphasized.
Infographic: Numbered callouts 1-5 alongside the row: Date, Time, Medication, Reason (quoted), Initials.
Shot: MS Michele on camera with a split-screen reference of the completed front + back; B-roll inserts (clock, dose cup) for the Q&A; close on Michele + disclaimer footer.
Camera: Return to medium shot; picture-in-picture the completed MAR; end on centered Michele for the sign-off.
Avatar: Michele on-camera; slight lean-in on 'front and back, every time'; calm close.
Visual: Tie the two marks together as one finished record; answer the real-shift objections.
Animation: Completed front + back slide together into one reference still; closing chip fades in.
Infographic: Q&A cards (changed-mind, no-time); closing chip 'Front + back, every time'; disclaimer footer 'APD-aligned educational content. Not an APD-approved training program.'
Annotated MAR front, Spiriva row, 1/9 8 AM cell highlighted; built on APD Form 65G-7.008 A layout.
🖼 image prompt: Clean flat-vector medication administration record (MAR) grid, top-down, one highlighted medication row labeled 'Spiriva inhaler', day columns with '1/9' emphasized, time-slot rows including '8 AM'; neutral clinical palette, high legibility, no real names beyond the synthetic client, no logos. Layout faithful to a generic Florida APD MAR form. [APD]
Refusal-symbol animation: legend initials 'M.D.' with a hand-drawn circle drawn around them (~0.6s), then a soft 'REFUSED' stamp.
🖼 image prompt: Two initials 'M.D.' in handwritten style inside a single MAR cell, a clean circle drawn around them, small 'REFUSED' caption; transparent background, SVG-friendly high contrast. [APD] pending TODO(source-L36-1) confirmation of the exact mark.
🎬 video prompt: 0.6s SVG path animation: a circle strokes clockwise around the initials 'M.D.'; then a subtle 'REFUSED' label fades in; no camera move; transparent background. [APD]
Annotated MAR back Comments table; one row fills element-by-element with numbered callouts 1-5.
🖼 image prompt: Flat-vector back-of-MAR 'Comments' table, one empty highlighted row, numbered 1-5 callouts beside it reading Date, Time, Medication, Reason, Initials; neutral clinical palette; synthetic content only. [Waiver360-added] five-element layout.
🎬 video prompt: Sequential type-on animation: into one comment row, fields appear in order - '1/9', '8 AM', 'Spiriva', quoted 'I'm tired of it', 'M.D.'; quotation marks briefly emphasized; no camera move. [APD]+[Waiver360-added]
Signature-legend close-up: printed name, signature, initials columns; 'M.D.' highlighted with a link line up to the cell mark.
🖼 image prompt: Bottom-of-MAR signature legend strip with columns Printed Name / Signature / Initials, one row highlighted showing initials 'M.D.'; clean vector, clinical neutral palette. [APD]
Side-by-side completed front + back of the Don Montana 1/9 refusal as a single reference still.
🖼 image prompt: Split composition: left = MAR front cell with circled 'M.D.' refusal mark; right = back-of-MAR comment row reading date/time/Spiriva/quoted reason/M.D.; unified caption 'Front + back, every time'; clinical neutral palette. [APD]+[Waiver360-added]
'I'm tired of it' speech-bubble caption card with quotation marks emphasized.
🖼 image prompt: Stylized speech bubble containing the quoted phrase "I'm tired of it.", quotation marks emphasized; warm neutral background; no faces. [APD] (client quote from MAR-DM 2b).
🎬 video prompt: Speech bubble scales in with a soft bounce; quotation marks pulse once; 1.5s; transparent background. [APD]
Target runtime: 4:00 · 5 chapters · not rendered (url: null)
Learner drags one of several symbol tokens onto a single target cell in a rendered MAR grid (medication row x day column x time slot). Correct placement + correct token both required. Wrong token or wrong cell fires the token/cell-specific rationale and routes to remediation.
Learner types a free-text response into a length-limited field. A rubric of required elements is scored by case-insensitive pattern match; the item passes at a configurable threshold (e.g. 4 of 5). Sub-threshold routes to remediation with element-level feedback on what was missing. Pattern-only grading (no model/LLM in the runtime).