Phase: Medical Record
| Field |
Value |
| Identifier |
healthcare-13-5 |
| Status |
Planned |
| Owner |
Platform |
| Module(s) |
healthcare.medical_records, healthcare.encounters, healthcare.clinical_lists |
| Service(s) |
healthcare |
| Depends On |
healthcare-13-0, healthcare-13-2 |
| ADR(s) |
TBD |
| Manifest |
phase-manifest.yaml |
| Framework |
ADR-013 · ADR-018 · ADR-019 |
Objective
Introduce structured medical record shells: MedicalRecord per patient, Encounter linked to VisitSession/Appointment, conditions/allergies/medications lists, immunization refs, and access-control policies — without national EHR exchange, mandatory HL7/FHIR compliance, or pharmacy dispensing.
Enterprise Phase Discovery
Required before Implementation.
| Field |
Value |
| Discovery date |
TBD at implementation |
| Inputs reviewed |
Phase 13.2 visit sessions · privacy/regulatory non-goals |
Target Responsibility (this phase when Complete)
- MedicalRecord aggregate (one per patient per clinic or tenant policy)
- Encounter records with immutable finalized state
- Clinical list items: Condition, Allergy, MedicationStatement (shells)
- ImmunizationRecord refs
- MedicalRecordAccessPolicy (doctor role, department, break-glass audit)
- Append-only clinical audit for record access and amendments
- Permissions
healthcare.medical_records.*, healthcare.encounters.*
- Events
healthcare.medical_record.*, healthcare.encounter.*
Explicitly Excluded
- Sports Center
medical_information (sports clearance only)
- National health information exchange
- AI diagnosis / treatment recommendation
- Pharmacy inventory and dispensing (13.6)
- Binary imaging PACS (Storage refs only)
Business Analysis
| Item |
Detail |
| Actors |
Doctor, authorized clinic staff, patient (read subset via 13.4 later) |
| Business capabilities |
Document encounters; maintain problem/medication/allergy lists |
| Success metrics |
Finalized encounters immutable; access logged |
| Non-goals |
Legal e-signature archive, regulated prescription format |
Scope
In Scope
- Aggregates: MedicalRecord, Encounter, Condition, Allergy, MedicationStatement, ImmunizationRecord, MedicalRecordAccessLog
- Lifecycle: encounter draft → in_progress → finalized (immutable)
- Amendment pattern for finalized records (addendum, not silent edit)
- Storage refs for attachments/lab results metadata
- Alembic
0006_phase_135_medical_record; version 0.13.5.0
Domain Model
| Aggregate |
Entities |
Invariants |
| MedicalRecord |
Encounter, Condition, Allergy, MedicationStatement |
Patient-scoped; access policy enforced |
| Encounter |
— |
Links VisitSession; finalized = immutable body |
Out of Scope
- Pharmacy orders (13.6)
- Delivery of supplies (13.7)
- Accounting clinical billing codes
- Patient portal full record export (partial read may extend 13.4)
Completion Criteria
Related Documents
5c6a2e78cf