# ROUNDS — Medical Resident Complete AI OS

    ## Setup, Benefits, Care-Orchestration & Agent-Management Guide

    > **Please allow time.** ROUNDS is a substantial one-file installation and may require several Hermes turns. It does **not** continue in the background. Keep the S0, S1, and S2 receipts, remain in the installation conversation, and wait for the final ROUNDS Activation Report.

    **Complete program:** `MRAIOS-ROUNDS-COMPLETE-1.0`  
    **Foundation:** `MRAIOS-LIFE-TRAINING-PRACTICE-1.0`  
    **SuperPowers overlay:** `MRAIOS-ROUNDS-1.0`  
    **Lane:** `medical_resident`  
    **Namespace:** `medres_rounds.*`  
    **Resident-only home:** `My ROUNDS`  
    **Starting state:** Private Resident OS • no PHI • no patient-specific live care • session-only memory • connectors Off • external actions Off • all 24 powers inactive • all agents Disabled

    ## What ROUNDS is

    ROUNDS is a resident-controlled operating system for the whole reality of graduate medical training: duty and rotation readiness, deliberate learning, supervised communication, care-orchestration preparation, feedback and development, exams and credentials, teaching, quality, research, fellowship and career, finances, family, recovery, purpose, and ethical software-agent management.

    **Promise:** Learn deliberately. Orchestrate reliably. Escalate early. Live beyond training.

    ROUNDS does not practice medicine, accept responsibility, expand graduated responsibility, or replace an attending, clinical team, Program Director, CCC, GME office, quality or risk team, IRB or HRPP, data steward, institution, interpreter, accommodation process, legal or financial professional, or emergency route.

    ## A separate page and lane—by design

    ROUNDS creates its own `medical_resident` lane, `/medical-residents` route, `medres_rounds.*` records, and **My ROUNDS** home. It does not share a profile, schema, dashboard, memory, permission, agent, activity history, or automation with a nursing population. If Hermes cannot prove isolation, installation stops and asks for a separate Medical Resident workspace.

    This matters because a resident's authority, supervision, duty rules, evaluation, medical credentials, research obligations, and clinical context are different. PGY, title, confidence, procedure count, technical access, and prior performance do not independently grant authority.

    ## What ROUNDS can help the resident do

    - bring a rotation, call schedule, learning plan, credential timeline, family commitments, recovery, and career goals into one resident-owned view;
    - keep the current supervising or attending route, task-level responsibility, source, and escalation trigger visible;
    - learn from current official sources and clearly synthetic cases without turning a private AI into a point-of-care system;
    - prepare human-owned handoffs, consult questions, transitions, closed loops, and interdisciplinary dependencies through CIRCLE;
    - organize feedback and Milestones self-evidence without surveillance, scoring, CCC simulation, or program access to private reflection;
    - prepare accessible teaching, quality, safety, research, scholarship, fellowship, contract, and career work with exact governance gates;
    - protect sleep opportunity, safe transport, health-care time, relationships, caregiving, finances, joy, purpose, and a future beyond training;
    - create narrow software-agent charters, test them synthetically, restrict their permissions, review every run, and stop or remove them.

    These are intended benefits, not guaranteed patient outcomes, board passage, promotion, Milestone level, fellowship match, reduced burnout, improved wellbeing, productivity, or financial results.

    ## ROUNDS means

    - **R — Ready** the resident for role, duty, call, recovery, and life.
    - **O — Orchestrate** reliable preparation across teams, consults, handoffs, dependencies, and transitions.
    - **U — Understand** evidence, reasoning, uncertainty, bias, and limits.
    - **N — Navigate** supervision, feedback, credentials, career, and opportunity.
    - **D — Develop** as communicator, teacher, quality leader, researcher, scholar, and professional.
    - **S — Steward** AI agents, data, sources, time, finances, family, health, purpose, and future.

    ## Three control frameworks

    ### ATTEND — authority before output

    - **Activity & active hat**
    - **Training level & task responsibility**
    - **Team & attending**
    - **Environment, evidence & data**
    - **Need for escalation**
    - **Decision, documentation & destination**

    If a consequential field is unknown, stale, expired, or conflicting, ROUNDS prepares questions and escalation. It does not fill the gap with confidence.

    ### CIRCLE — human-owned care orchestration

    - **Context & goals**
    - **Identified accountability**
    - **Roles, relationships & consults**
    - **Closed loops & contingencies**
    - **Limits, uncertainty & escalation**
    - **End state & transition**

    CIRCLE makes the decision owner, action owner, receiver, accountable attending, source, acknowledgment, escalation, and expiry visible. In Private mode it is synthetic or process-only. In a separately approved clinical workspace it may prepare a draft, but the official EHR and team remain the source of truth, a human reconciles every item, and AI never transfers responsibility or decides care.

    ### ORBIT — control every software agent

    - **Objective & owner**
    - **Role, risk & responsibility**
    - **Boundaries & budget**
    - **Inspect & test**
    - **Transfer or terminate**

    Every agent starts Disabled. It needs a narrow charter, P0–P4 permission, exact data and tools, human owner, synthetic and failure tests, one-run approval, inspectable receipt, expiry, purge, rollback, and kill switch. P5 actions—autonomous clinical decisions or actions, surveillance, scoring, evaluation, credential decisions, hidden persistence, and permission escalation—are prohibited.

    ## The 24 optional SuperPowers

    1. **Rotation & Call Readiness Navigator** — Build a feasible day, night-float, call, clinic, conference, study, commute, recovery, and protected-life plan without patient assignments or fitness-for-duty conclusions.
2. **Duty-Hours, Fatigue & Safe-Transport Shield** — Make schedule pressure, post-call recovery, duty-hour questions, and transport options visible without diagnosing fatigue, impairment, burnout, health, or readiness to practice.
3. **Capacity, Leave, Recovery & Human-Support Navigator** — Protect education, health care, leave, relationships, recovery, and human support while preventing the AI from deciding accommodations, employment rights, impairment, or program standing.
4. **Mission, Finances, Family & Future Compass** — Connect professional identity to debt, benefits, family, relocation, joy, service, leadership, and a private long-term life direction outside program analytics.
5. **Supervision-Aware Care Orchestration Mapper** — Apply care-orchestration principles to synthetic or separately authorized work while keeping the attending or supervising physician, official systems, and current patient-specific decisions in control.
6. **Consult, Interdisciplinary Team & Closed-Loop Coordination Studio** — Rehearse consult questions, role clarity, dependencies, closed-loop communication, and escalation without contacting a team, placing an order, or moving live care.
7. **Handoff, Cross-Cover & Transition Reliability Rehearsal** — Practice structured transitions with fictional or approved training scenarios; never create a real handoff, sign-out, patient list, or shadow record.
8. **Follow-Up, Barrier & Contingency Reliability Planner** — Map access, equity, logistics, dependencies, contingency triggers, ownership, and follow-through in synthetic or authorized workflows without creating patient tasks or promises.
9. **Evidence, Guideline & Uncertainty Navigator** — Build source-aware evidence briefs with versions, applicability, uncertainty, contradictions, and attending verification—never autonomous patient-specific recommendations.
10. **Synthetic Clinical Reasoning & Diagnostic Calibration Lab** — Practice differential construction, problem representation, uncertainty, bias checks, and escalation using fictional cases; it never scores competence or directs real care.
11. **Journal Club, Adaptive Learning & Knowledge Synthesis Studio** — Turn questions into verified learning plans, journal-club briefs, spaced review, and adaptive-learning cycles with transparent sources and limits.
12. **Quality, Patient Safety & Implementation Lab** — Prepare systems-focused quality and safety work, measures, PDSA cycles, and learning reviews without copying events, deciding cause or reportability, or changing care.
13. **Graduated Responsibility, Supervision & Escalation Compass** — Show active PGY, rotation, site, task, required supervision, procedure authority, escalation route, and human decision owner without granting independence.
14. **Milestones, EPAs, Feedback & Development Map** — Organize self-reflection and formative goals while keeping milestone ratings, CCC decisions, promotion, remediation, probation, discipline, and competence determinations human.
15. **License, Exam, Procedure Authorization & Credential Radar** — Track official requirements, expiries, exams, training permits or licenses, procedure authorization, logs, certifications, and human verification without certifying status.
16. **Fellowship, Career, Contract & Opportunity Navigator** — Build truthful applications, portfolios, opportunity comparisons, negotiation questions, mentorship routes, and transition plans fitted to actual capacity.
17. **Human Communication, Consent & Difficult-Conversation Rehearsal** — Prepare patient-centered and team communication using synthetic scenarios, with uncertainty, teach-back, cultural humility, interpreter planning, and attending ownership.
18. **Teaching, Bedside Education & Case-Conference Studio** — Create source-aware micro-teaching, morning-report, conference, and learner-support plans without identifiable cases, unofficial grading, or authority inflation.
19. **Research, Scholarship, Authorship & Professional Voice Forge** — Prepare ethical research questions, abstracts, posters, presentations, authorship maps, disclosures, and public voice with exact institutional review and team credit.
20. **Feedback, Conflict, Mistreatment & Psychological-Safety Navigator** — Help the resident seek and use feedback, prepare difficult conversations, and find program, GME, ombuds, HR, union, accommodation, or safety routes without deciding rights or retaliation claims.
21. **AI Agent Charter, Tool, Permission & Data Registry** — Define each software agent's objective, owner, role, model, tools, sources, allowed data, prohibited actions, human checkpoints, expiry, and retirement before any run.
22. **Multi-Agent Orchestration & Human-Handoff Designer** — Design bounded agent sequences, dependencies, review order, conflict handling, and exact handoffs to residents, supervisors, and authorized owners using synthetic tests.
23. **Agent Output, Source, Bias, Security & Trace Auditor** — Inspect agent evidence, provenance, prompt injection, bias, drift, disagreement, action state, and human edits without treating agent consensus as truth.
24. **Agent Incident, Pause, Failover, Rollback & Retirement Controller** — Provide visible pause, containment, incident routing, safe manual fallback, rollback, expiry, removal, and learning receipts for every governed agent.

    All 24 install inactive. Begin with zero or one low-risk power. Activation is optional.

    ## Two deployment contexts

    ### 1. Private Resident OS — default

    Use for resident-owned schedules, duty entries, recovery, generic evidence, synthetic cases, deidentified reflection that passes the privacy screen, feedback preparation, exams, credentials, career, finance categories, family, purpose, and whole-life planning.

    Do not enter PHI; patient-specific live-care questions; chart, EHR, handoff, sign-out, consult, order, note, event-report, patient-list, or patient-message content; screenshots; recordings; identifiable stories; restricted institutional information; credentials; secrets; or private keys. Removing a name is not enough to make clinical material safe for a personal/public AI.

    ### 2. Institution-Approved Workspace — separately provisioned

    The institution must separately approve the exact platform, role, purpose, vendor and model, applicable agreement, data class, source, minimum necessary, access, logging, retention and deletion, monitoring, incident route, and human owner. Clinical, education, quality, research, and administrative subcontexts remain separate. Installing ROUNDS does not create or certify this environment.

    If approval cannot be verified, return to Private mode and remove patient or institutional content. Never copy approved institutional content into Private memory, an agent trace, a career portfolio, or a whole-life export.

    ## Before installation

    1. Use a private authenticated workspace controlled by the resident or an explicitly isolated resident setup.
    2. Prepare the single file `Medical-Resident-Complete-AI-OS-with-ROUNDS-SuperPowers-Hermes-Program.md`.
    3. Do not place PHI, live patient information, chart or event content, screenshots, recordings, restricted institutional material, credentials, tokens, or identifiable stories in the file or installation conversation.
    4. Know the resident's specialty, PGY, site, current rotation or service, active hats, and human attending or supervision route. It is acceptable to mark details `Unknown — human verification required`.
    5. Identify the current program or site source for supervision and duty rules; do not rely on a hardcoded universal rule.
    6. Decide one protected-life commitment and the desired privacy or sharing choice.
    7. Expect several Hermes turns. Nothing continues after the conversation ends.

    ## Install the Complete Edition

    1. Give Hermes the entire one-file program; do not split or paraphrase it.
    2. Use the Single installation prompt near the top of the program.
    3. Let Hermes complete read-only preflight. If the target is shared with another population, stop and create a separate Medical Resident workspace.
    4. Answer the minimum questions one at a time. Use **Skip**, **Not now**, or **Use this session only** whenever desired.
    5. Review the one combined Activation Card. Confirm lane, namespace, context, supervision source, allowed and prohibited data, human owners, Off states, protected life, burden, stop, expiry, rollback, and removal.
    6. Approve only the exact card. Silence and timeout are not approval.
    7. Keep S0, S1, and S2 receipts. If interrupted, use the exact resume command in the program.
    8. Wait for the final ROUNDS Activation Report. All powers and agents remain inactive afterward.

    ## Installation phases

    | Phase | What Hermes does | Receipt or result |
    |---|---|---|
    | 0 | Read-only preflight and isolation check | No mutation |
    | 1 | Minimum questions and one combined card | Awaiting exact approval |
    | 2 | S0 snapshot, foundation, lane, Trust Shield, ATTEND, My ROUNDS shell, 72 checks | S1 |
    | 3 | CIRCLE, ORBIT, six pillars, dashboard views, 24 inactive powers, 10 Disabled agents, workflows, templates | S2 |
    | 4 | 72 overlay-domain checks and 16 integration checks | Passed or Blocked |
    | 5 | Activation Report, first safe use, recovery and review | Complete |

    ## My ROUNDS dashboard

    The sole resident home opens with:

    1. **Orient My Day & Duty**
    2. **Learn & Reason**
    3. **Orchestrate & Communicate**
    4. **Review, Escalate & Close**

    The optional fifth launcher remains empty until the resident separately approves one. The opening view contains no more than seven attention items and keeps the active hat, program, specialty, PGY, site, rotation, supervision, accountable attending route, context, source freshness, duty and recovery, human decision queue, power state, agent state, and permanent controls visible.

    Permanent controls include Context and Active Hat; Supervision and Attending; Privacy and Data; Sources and Freshness; Duty and Recovery; Human Approval Queue; Agent Registry and Kill Switch; History; Pause All; Safe Reset; Correct; Export; Delete; Rollback; Remove Power; and Full Uninstall.

    ## First safe use

    Only after the Activation Report, ask Hermes:

    > Open My ROUNDS in the isolated Medical Resident lane and Private Resident OS. Use only resident-owned nonsensitive information, public sources, and clearly synthetic examples. Show my active hat, program, specialty, PGY, site, rotation or service, task-level supervision source and expiry, accountable attending or human route, Top Three, recovery and protected-life commitment, one learning priority, one synthetic or process-only CIRCLE item, human decision queue, source freshness, all 24 power states, all agent states, and permanent Privacy, Pause All, and Kill Switch controls. Label every unknown, stale source, AI interpretation, conflict, missing owner, and human-verification need. Do not request or use PHI, patient-specific live-care information, institutional data, EHR or event content; do not save new memory, connect, share, send, schedule, report, publish, release, activate, automate, infer authority, or change care. Help me choose one low-risk First Ritual and create a one-page resident-controlled artifact with an expiry.

    Good first rituals: rotation orientation; day or call plan; post-call recovery and safe-transport plan; generic evidence brief; synthetic reasoning case; synthetic CIRCLE rehearsal; feedback-conversation prep; exam plan; microteaching outline; fellowship calendar; or private whole-life Minimum Mode.

    ## Safe care-orchestration practice

    Start with a fictional scenario. Name the accountable attending, resident role, decision owner, action owner, receiver, source, pending dependency, acknowledgment evidence, escalation trigger, official destination, and expiry. Ask: Who owns the decision? Who acts? Who receives? What proves the loop closed? What happens if it fails? Where does the human-approved result live? What must expire at transition?

    A handoff is a human-to-human transfer of information and responsibility. An AI draft or electronic transmission does not equal receipt or acceptance. Consult recommendations remain attributed, and the primary team and attending retain human decision ownership. ROUNDS never creates a private patient list or shadow sign-out.

    ## Safe first agent

    Use a P1 synthetic **Source & Claim Verifier** or **Day & Capacity Planner**:

    1. Write one objective and non-goals.
    2. Name the resident owner and the human decision owner.
    3. Allow only synthetic or resident-owned nonsensitive input; no tools or external action.
    4. Define evidence, uncertainty, time and cost limit, expiry, purge, and kill switch.
    5. Preview the exact plan and output.
    6. Test one normal, one missing-source, one prompt-injection, and one tool-failure case.
    7. Approve one bounded run or leave it Disabled.
    8. Independently review, accept or reject, save a nonsensitive receipt, then purge or expire.

    Agent consensus is not evidence. A verifier agent is not a supervisor or human approval. No agent activates another, expands its charter, hides a transfer, or retries silently.

    ## Non-negotiable boundaries

    - No PHI or live patient care in Private mode.
    - No autonomous diagnosis, triage, prescribing, order, procedure, consent, disposition, note, signature, page, consult, handoff, patient message, event report, or monitoring.
    - No inference of graduated responsibility, supervision, competence, procedure authorization, credential, Milestone, or program approval.
    - Immediate clinical safety concerns go to the local human clinical and emergency route without delay.
    - No resident, staff, learner, or patient surveillance, ranking, risk score, productivity score, professionalism prediction, burnout or impairment classifier, or automatic program report.
    - No AI determination of QI versus research, reportability, root cause, fault, IRB status, authorship, compliance, or legal rights.
    - No fabricated evidence, citation, achievement, evaluation, credential, data, result, or case presented as real.
    - No software agent receives clinical authority, self-approval, recursive delegation, hidden persistence, permission escalation, or unrestricted data.
    - No background continuation. No timeout equals approval. No hidden action.

    ## Recovery

    - **Pause All:** immediately stops new and pending powers, agents, connectors, schedules, and external actions while keeping human safety routes visible.
    - **Safe Reset:** returns to the isolated Private Resident OS, no PHI, session-only memory, connectors and actions Off, agents Disabled, Core Four, empty fifth launcher, and all powers inactive.
    - **Remove one power:** preview its dependent views, records, permissions, agents, and runs; choose export or purge; preserve the foundation and unrelated work.
    - **Remove ROUNDS overlay:** remove SuperPowers and overlay views while preserving the resident foundation and My ROUNDS shell.
    - **Full uninstall:** preview restoration of S0, preserve unrelated work, and issue a receipt.
    - **Sensitive-data event:** stop; do not repeat the content; prevent further use or retention where controls allow; and use the authorized privacy, security, clinical, quality, research, or incident route.
    - **Agent incident:** kill or pause; contain; preserve only appropriate nonsensitive evidence; use manual fallback; route to the authorized owner; verify rollback and purge; do not self-restart.

    ## Release assurance

    ROUNDS contains 72 foundation-domain checks, 72 SuperPower-domain checks, and 16 integration checks: **160 total**. Critical privacy, patient safety, supervision, duty, care-orchestration, handoff, evaluation, QI or research, data, source, no-surveillance, accessibility, agent, external-action, and recovery checks must pass. A human-verification blocker remains visible and prevents activation.

    ## Current source watch

    At installation and material change, Hermes should verify current ACGME Common Program Requirements and specialty requirements; program and institutional supervision and duty policies; ACGME Milestones, CCC and CLER guidance; specialty board and state licensing sources; institutional credentialing; HHS HIPAA minimum-necessary and de-identification guidance; research, QI, privacy, security, accessibility, and interpreter requirements; AAMC and AMA AI guidance; AHRQ TeamSTEPPS communication and handoff resources; and applicable state and institutional rules.

    The included source links are a watchlist, not permission or a substitute for current local interpretation. As of this pack's release, AAMC's cross-continuum AI competencies remain in development; ROUNDS does not claim compliance with a future final competency set.

    ## Final reminder

    ROUNDS gives the resident wings through clarity, deliberate practice, reliable human coordination, governed leverage, and a protected future—not through unsupervised authority. AI prepares and checks. Residents reason, learn, communicate, escalate, and live. Attendings, teams, programs, institutions, and qualified humans decide and remain accountable.
