Varde - Discharge Follow-up Platform with Nurse Triage and Municipal Handover
Discharge Follow-up for a Norwegian Hospital Trust
Designed and built a clickable discharge follow-up platform for a Norwegian health trust's cardiology and orthopaedic wards: patients enrolled at discharge answer check-ins on their phone, answers that cross a programme threshold land on a nurse triage worklist, and handovers go to the GP or municipal home nursing as standard messages over Norsk Helsenett.
Most of our work is under NDA. Per agreement, we can share the work but not the company details - all names and identifying information shown here have been changed.
Impact
Dashboard, triage worklist, alert workspace, discharges with a 5-step enrol panel, and handovers. Every one of the 22 demo alerts opens its own workspace.
Red alerts have a 30-minute target in service hours, amber 4 hours and info 24 hours. Each alert's age turns amber at half its target and red when over.
From chest pain at rest and weight up more than 2 kg in 3 days to a blood thinner not taken for 2 days. Each rule sets the severity and what the patient is shown, such as "call 113 now".
22 enrolments across 4 programmes on 2 wards, 22 alerts, 16 discharges, 17 handover messages and 11 catchment municipalities with their HER-ids.
The Problem
Vesterfjord's wards followed patients up with a phone call "within a week", when a nurse had time, logged on paper lists, so nobody knew how many patients were never reached. Heart attack patients stopped their blood thinners and nobody heard until the GP saw them weeks later, wound photos sat in a general inbox over the weekend, and requests to municipal home nursing went by phone with nothing in the patient's journal.
Our Solution
Varde enrols patients on a condition-based programme before they leave the ward and sends them daily and weekly check-ins. Answers that cross a threshold raise an alert on one triage worklist, the nurse calls back and logs the outcome, the journal note is written back to the EPR, and escalations go to the GP or home nursing as PLO and dialogue messages.
The Challenge: Follow-up Between Hospital and Home
Once a patient goes home, responsibility is shared between the hospital, the GP and the municipality, under Norwegian rules on patient rights, documentation, access to records and cooperation between services.
Answers That Need a Nurse Now
Chest pain at rest, a fever after a hip replacement or a missed blood thinner each need a different response time. Varde is not an emergency service, so red-flag answers must tell the patient to call 113 straight away, before any nurse sees the alert.
Every Call Belongs in the Journal
The Health Personnel Act requires care to be documented in the patient record. The EPR stays the source of truth for discharges, diagnoses and medicines, so every triage call and decision has to go back to it as a journal note.
Access Only With a Care Relationship
Under the Patient Records Act, staff may only read a patient's data when they take part in their care. Access has to follow ward and programme, every view of a patient is logged, and the trust must be able to tell a patient who looked at their data.
Handover to Eleven Municipalities
Home nursing and GPs work in their own systems. Messages have to go as standard PLO and dialogue messages over Norsk Helsenett to the right receiver in the national address register, with a receipt the ward can check.
Our Approach: From Follow-up Rules to a Clickable Platform
Spec and Rules Research
Mapped 11 user roles, 38 screens (29 for staff and 9 for the patient app) and the data model for programmes and versions, threshold rules, enrolments, check-ins, wound photos, alerts, call logs, journal notes, handover messages and readmission reviews. Wrote down the rules the design follows: patient rights and consent, documentation and confidentiality, access by care relationship, GDPR, Normen, ID-porten login, hospital and municipality cooperation, the 30-day readmission indicator and the EU MDR.
Clickable Demo on a Production UI Kit
Built 5 key screens on a production dashboard kit: the dashboard with KPIs, check-ins by day and open alerts by severity, the triage worklist with red alerts pinned, bulk actions and a patient quick view, the three-column alert workspace with trends against thresholds, wound photos and an editable journal note, discharges with eligibility hints and the enrol panel, and handovers with receipt status and replies. All actions run on local state.
What a Production Build Adds
Integration with the EPR (such as DIPS Arena through its Open API or HL7 FHIR) for discharges, medicines and journal write-back, ID-porten for patients, single sign-on with multi-factor login for staff, Norsk Helsenett messaging with Adresseregisteret lookup, and SMS and push reminders. An append-only audit log, the patient app, programme builder, reports and settings, and confirmation of the product's position under the EU MDR before go-live.
Why It Works: The Right Alert to the Right Nurse
Red Alerts Are Never Buried
Red alerts sit in their own pinned group at the top of the worklist whatever the sort order. Each row shows what triggered it in plain words, such as "Pain at rest 8/10, was 4 yesterday", and what the patient was already told to do.
One Screen to Decide and Document
The alert workspace puts the patient, the discharge summary with medicine changes, the check-in answers next to the previous ones and the trend charts in one view. Closing an alert needs an outcome and a journal note built from the call log.
Enrolment Built Into Discharge
Today's discharges come from the EPR with a suggested programme. Hints flag patients with no Norwegian ID number, discharge to another hospital or a short-term municipal bed, and declines are recorded with a reason such as no smartphone.
Handovers the Ward Can Track
Each message shows its receiver and HER-id, its type and its receipt status. Messages with no receipt after 24 hours and failed sends get their own tabs, and replies from home nursing wait until a nurse marks them handled.
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Enterprise Software Engineering - Human + AI
Contact Us
Locations
Global Headquarters
21 Merchant Road, 3rd Floor, Singapore 058267
Main corporate office and leadership operations
North America Office
548 Market Street, PMB 12345, San Francisco, CA 94104
Client operations and business development
India Office
402 Shivalik Shilp II, SG Highway, Ahmedabad 380015
Engineering and delivery center
© 2026 - Copyright. All Rights reserved Oceanlab