Care record & care delivery

Combine care needs, goals and recurring interventions into a traceable plan and automatically prepare evaluations as they become due.

Record care needs, goals, interventions, frequency, period, responsible competence and evaluation criteria in structured form; each approved version remains immutable.

Distinguish between a draft plan, the clinically confirmed active revision, a superseded revision and an ended intervention. Intended validity is not the same as the time of entry.

Changes must specifically invalidate affected future care delivery instructions. Past delivery permanently references the plan revision valid at the time.

Derive evaluation deadlines, open queries and delegable activities with assigned responsibility. Missing information about needs is unknown, not a denial.

Plan changes with clinical significance require a current competence and relationship check and explicit approval; templates are versioned and never silently copy resident values.

Responsibility

Qualified care professionals plan and confirm within their competence; assistants record proposals or assigned data; management sees outstanding evaluations and escalates them.

Automation & AI

AI suggests wording, goals and summaries from approved sources; it has no independent write or approval right. Confirmation binds the input, knowledge, prompt and plan revisions. AI features require activation at your request. Processing remains on Oronela's own servers in Switzerland.

Connection & offline use

Read the approved, assigned plan with an indication of its currency and draft changes locally; binding clinical approval of the plan is online only.

Document safely at the bedside, avoid repetition and clearly distinguish actual care from drafts, plans and later retrospective entries.

Record vital signs with unit, measurement method, time and source, pain, wounds with approved images and care incidents in a structured format plus free text; version limits and justified clinical exceptions.

Every care delivery entry names the actual time, person carrying out the care, documenting actor, plan revision and any deviation. An entry confirms only services actually delivered.

Switching residents invalidates open entry contexts that affect safety; attachments, dictation and measurements must be assigned to the visibly confirmed person.

Never overwrite signed entries: additions or corrections include a reason, author, reference to the original and their own approval. Explicitly record the meaning of the signature and the signed data revision.

Drafts produced through speech input or AI retain the original input where permitted, the result, source version and review decision. Simply accepting an autocomplete suggestion does not constitute approval.

Photos and attachments use only a protected object port with permissions, metadata checks and content checks; no private device gallery or automatic unprotected backup.

Responsibility

Qualified nursing staff record and sign within their area of competence; assistants carry out delegated actions; wound and image access is controlled separately. The person documenting and the person who actually performed the action must never be silently treated as the same person.

Automation & AI

Local dictation and writing assistance produce explicitly reviewable drafts. Negations, similar doses and units, incorrect resident references and invented observations are separate evaluation case categories; clinical confirmation remains human. AI features require activation at your request. Processing remains on Oronela's own servers in Switzerland.

Connection & offline use

Observations and reports are encrypted local drafts within the lease; a local journal is written before confirmation. The server rechecks permissions and revisions; clinical signatures and binding plan changes require an online connection. Medication administration belongs exclusively to M03-C.

Reliably hand over outstanding, time-critical work at shift changes and avoid duplicate queries through a shared current task view.

The handover brings together permitted resident updates, open tasks, queries and time-critical deviations; the data status and revisions used are visible.

Each task has a responsible person or role, substitute, due date, acknowledgement and escalation. The end of a shift must not remove responsibility.

Delegation requires valid competence and named supervision where clinically necessary; accepting a delegation and actually completing it are different actions.

Handover confirmation binds the version seen. New critical incidents after preparation mark the summary as outdated and require acknowledgement.

Views and exports remain limited to the unit and resident; team membership alone does not grant access to all records. Bulk actions must never confirm care that was not delivered.

Responsibility

Outgoing and incoming nursing staff, delegated staff and unit management work within active assignments; escalation permissions are separate from clinical handling.

Automation & AI

AI summarises confirmed changes with evidence links and flags uncertainty. It must not remove outstanding tasks from the list, decide competence or acknowledge a handover; a complete deterministic list is shown alongside it. AI features require activation at your request. Processing remains on Oronela's own servers in Switzerland.

Connection & offline use

Read assigned tasks and provisionally record non-critical notes; accepting a handover, new delegation and changes to deadlines or responsibility require an online connection. An offline view does not promise a current transfer of responsibility.