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Version: 1.0.0
Last Updated: 2026-01-28
Module: GR (Governance & Risk)
Status: Active
Purpose: This guide helps compliance officers and administrators create, manage, and monitor procedures.

Overview

The Procedures Management module enables compliance officers to create visual step-by-step procedures, link them to policies, track executions, and use AI to generate procedure drafts.

Admin Responsibilities

ResponsibilityDescription
Create ProceduresBuild visual workflows with step-by-step instructions
Manage LifecycleMove procedures through draft → review → approved
Link to PoliciesConnect procedures to implementing policies
Monitor ComplianceTrack procedure execution across the organization
Use AI GenerationGenerate procedure drafts from policy content

Prerequisites

Required Permissions

Administrators need these permissions:
PermissionPurpose
gr.procedures.adminFull administrative access to procedures
gr.procedures.createCreate new procedures
gr.procedures.editEdit existing procedures
gr.procedures.approveChange procedure status
gr.settings.manageConfigure module settings

Creating Procedures

Quick Create

  1. Navigate to GR → Procedures
  2. Click Add Procedure
  3. Fill in required fields:
    • Title: Clear, descriptive name (e.g., “SOP-001: Medication Administration”)
    • Category: Clinical, Operational, Safety, HR, Financial, IT, Emergency, Other
    • Description: Brief overview of procedure purpose
  4. Click Save to create a draft

Using AI Generation

Generate procedure drafts from existing policies:
  1. Navigate to GR → Procedures → New
  2. Click Generate with AI button
  3. Select an approved policy from the dropdown
  4. (Optional) Add additional context for the AI
  5. Click Generate Procedure
  6. Review the generated steps and confidence score
  7. Click Apply to Procedure to populate the editor
  8. Edit and refine as needed
Note: AI generation is only available when AI features are enabled for your organization.

Visual Workflow Editor

Canvas Overview

The procedure editor uses a visual canvas where you can:
  • Add different step types
  • Position steps by dragging
  • Connect steps with edges
  • Configure step properties

Adding Steps

  1. Open procedure in edit mode
  2. Click step type button in the toolbar:
    • Action: Standard task
    • Decision: Branch point
    • Verify: Sign-off step
    • Reference: Link to document
    • System: Automated action
  3. New step appears on canvas
  4. Drag to position

Configuring Steps

Click on any step to open the properties panel:
PropertyDescription
TitleClear, concise step name
InstructionsDetailed step-by-step instructions
Responsible RoleWho performs this step (e.g., “Nurse”, “Manager”)
DurationEstimated time in minutes
Requires SignatureEnable for verification steps
Verification CriteriaWhat must be verified (for verification steps)
Decision OptionsBranch labels (for decision steps)

Connecting Steps

  1. Hover over a step’s bottom handle (output)
  2. Drag to another step’s top handle (input)
  3. Edge connects the steps
  4. Label edges as needed (especially for decisions)

Decision Branches

For decision steps:
  1. Add the decision step to the canvas
  2. Configure decision options (e.g., “Yes”, “No”, “Escalate”)
  3. Each option creates a separate output handle
  4. Connect each handle to the appropriate next step
  5. Label each edge with the decision option

Procedure Lifecycle

Status Workflow

StatusDescriptionWho Can View
DraftBeing created/editedCompliance officers only
ReviewUnder review before approvalCompliance officers only
ApprovedActive procedureAll staff
DeprecatedBeing phased outAll staff (with warning)
ArchivedHistorical recordCompliance officers only

Approving Procedures

Before approving:
  1. Review all steps and connections
  2. Verify linked policy (if applicable)
  3. Check that all steps have clear instructions
  4. Ensure responsible roles are assigned
To approve:
  1. Open the procedure
  2. Click Change Status button
  3. Select Approved
  4. Set effective date
  5. Procedure becomes visible to staff

Creating New Versions

When updating an approved procedure:
  1. Open the approved procedure
  2. Click Create Version
  3. Enter a change summary
  4. Version snapshot is created (immutable)
  5. Continue editing the current version
  6. Re-approve when changes are complete

Linking to Policies

  • Demonstrates policy implementation
  • Enables compliance traceability
  • Required for accreditation audits
  • Shows staff “the why” behind procedures
  1. Open procedure in edit mode
  2. Find “Implements Policy” dropdown
  3. Select the policy this procedure implements
  4. Link is created automatically
  5. Appears on both procedure and policy detail pages
TypeDescription
ImplementsProcedure implements the policy requirements
ReferencesProcedure references but doesn’t fully implement
RelatedProcedure is related to the policy

Monitoring Executions

Execution Dashboard

View all procedure executions:
  1. Navigate to GR → Procedures
  2. Open any procedure
  3. Click the Executions tab
Execution status breakdown:
StatusDescription
In ProgressCurrently being executed
CompletedSuccessfully finished
AbandonedStarted but not completed

Compliance Reporting

Use execution data for:
  • Track which procedures are being followed
  • Identify procedures with low execution rates
  • Audit execution records for accreditation
  • Verify staff compliance with SOPs

Execution Details

View execution details to see:
  • Who executed the procedure
  • When each step was completed
  • Notes added during execution
  • Decisions made at branch points
  • Electronic signatures captured

Module Settings

Available Settings

Navigate to GR → Settings → Procedures:
SettingDefaultDescription
procedure_number_prefix”SOP”Prefix for auto-numbering
procedure_review_reminder_days30Days before review due
procedure_auto_save_interval_seconds30Auto-save frequency in editor
require_policy_linkfalseRequire procedures to link to policies

Configuring Settings

  1. Navigate to GR → Settings
  2. Open “Procedures” tab
  3. Modify settings as needed
  4. Click Save

AI Generation Best Practices

Getting Good Results

  1. Select clear policies: Policies with detailed requirements generate better procedures
  2. Add context: Describe specific roles, environment, or constraints
  3. Review confidence score: Higher scores indicate better AI understanding
  4. Edit generated content: Always review and refine AI output

What AI Generates

  • Procedure title and description
  • Ordered steps with appropriate types
  • Responsible role suggestions
  • Time estimates
  • Verification points
  • Decision branches

What to Review

  • Verify step order makes sense
  • Check role assignments are correct
  • Ensure decision options are complete
  • Add organization-specific details
  • Remove any generic placeholder content

Troubleshooting

Common Issues

Issue: Staff Can’t See Procedure

Symptoms: Staff report procedure not visible Cause: Procedure may be in draft/review status Resolution:
  1. Check procedure status
  2. If draft/review, approve the procedure
  3. Set effective date if needed

Issue: AI Generation Not Working

Symptoms: Generate with AI button missing or failing Cause: AI features not enabled for organization Resolution:
  1. Verify AI compliance features enabled in GR settings
  2. Check LOVABLE_API_KEY secret is configured
  3. Contact administrator if still not working

Issue: Execution Not Recording

Symptoms: Steps complete but execution not saved Cause: Permission or connectivity issue Resolution:
  1. Check user has gr.procedures.execute permission
  2. Verify network connectivity
  3. Refresh page and try again

Escalation Path

If issues can’t be resolved:
  1. Check system logs for errors
  2. Review recent changes to procedures
  3. Contact technical support with:
    • Error messages
    • Steps to reproduce
    • User and organization details

Best Practices

Creating Effective Procedures

  • ✅ Keep step instructions clear and actionable
  • ✅ Use active voice (“Review the form” not “The form should be reviewed”)
  • ✅ Assign specific roles, not generic “staff”
  • ✅ Include time estimates for each step
  • ✅ Add verification steps after critical actions

Managing Procedures

  • ✅ Review procedures quarterly for accuracy
  • ✅ Update when policies change
  • ✅ Archive rather than delete outdated procedures
  • ✅ Use version history to track changes

Monitoring Compliance

  • ✅ Check execution rates regularly
  • ✅ Follow up on abandoned executions
  • ✅ Use execution data in audits
  • ✅ Identify training needs from execution patterns

Data Management

Version History

All procedure versions are stored:
  • Version snapshots are immutable
  • Change summaries document updates
  • Previous versions available for audit

Data Retention

Data TypeRetention PeriodNotes
Active proceduresIndefiniteUntil archived
Archived procedures7 yearsPer compliance requirements
Execution records7 yearsPer audit requirements
Version historyIndefiniteFor traceability

  • User Guide: docs/gr/procedure-user-guide.md - For staff members
  • Policy Admin Guide: docs/gr/policy-admin-guide.md - Managing linked policies
  • AI Compliance Guide: docs/gr/ai-compliance-admin-guide.md - AI features
  • Module Overview: docs/gr/index.md - GR module documentation

Last Updated: 2026-01-28
Technical Support: Contact your system administrator