Functional contract

SOAP notes

Clinical record for one visit. Organization-visible on the patient chart; authored at the visit’s Location. Appointments without a visit have no SOAP.

Structured SOAP + history shipped Voice-to-text deferred Source: docs/functional/soap-notes.md

Domain

Model	What it is
`SoapNote`	One per visit. jsonb columns: subjective, objective, assessment, plan
`PatientHistory`	Timeline of visits + appointments without a visit on the chart

Lazy find_or_create on first open (not at check-in). Partial notes allowed. No draft or signed/locked state.

Structure

S — CC, HPI, PMHx, social/environmental, dietary, meds/preventatives, ROS
O — Vitals/triage, PE by system (WNL/abnormal + notes; blank until marked), diagnostics (free-text plus visit-linked order results)
A — Problem list, differentials, working diagnosis, prognosis, progress (rechecks)
P — Further Dx (visit-linked orders), in-clinic Tx, discharge meds, client education, red flags, follow-up

Patient history

On GET /app/patients/:id, newest first:

Row	When
Visit	Every visit; linked appointment time as secondary meta (not duplicated)
Appointment	Materialized appointments with no visit (scheduled, canceled, no-show)

Cross-location. Virtual series slots excluded. Visit rows link to SOAP.

Routes

Route	Who
`GET /app/visits/:visit_id/soap_note`	`patients.read`
`GET/PATCH …/soap_note/edit`	`soap.manage` at visit Location

RBAC

Manage: org admin, location admin, veterinarian. Read: anyone with patients.read. Receptionist reads only.

Out of scope

Voice-to-text, mobile API, note lock/sign, billing Rx fulfillment, photos, SMS.

Full contract: docs/functional/soap-notes.md.