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Overview

The Medical Records module (Historial Clínico) allows doctors to document patient consultations, diagnoses, treatments, and future care plans. Each record is timestamped and linked to a specific doctor and patient.

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Creating Medical Records

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Access Points

Medical records are created from the patient profile page:
  1. Navigate to /patients/{uuid}
  2. Select the “History” tab
  3. Click ”➕ Nuevo registro” button (doctors only)
  4. Fill in the clinical record form
  5. Click “Guardar Evolución” to save
Only users with the CREATE_MEDICAL_RECORDS permission (typically doctors) can create new clinical records.

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Database Schema

CREATE TABLE medical_records (
    id INT AUTO_INCREMENT PRIMARY KEY,
    patient_id INT NOT NULL,
    doctor_id INT NOT NULL,
    record_date TIMESTAMP DEFAULT CURRENT_TIMESTAMP,
    motif TEXT,
    diagnosis TEXT,
    treatment TEXT,
    future_plan TEXT,
    next_visit DATE,
    observations TEXT,
    FOREIGN KEY (patient_id) REFERENCES patients(id) ON DELETE CASCADE,
    FOREIGN KEY (doctor_id) REFERENCES doctors(id) ON DELETE CASCADE
);

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Record Components

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Clinical Fields

Each medical record contains the following structured information:
Field: motifThe reason for the patient’s visit. What brought them to the clinic today?Example: “Dolor intenso en molar inferior izquierdo. 3 días de evolución.”
Field: diagnosisThe clinical diagnosis based on examination and symptoms.Example: “Caries profunda con compromiso pulpar — pieza 3.6”
Field: treatmentThe treatment performed during this visit.Example: “Extracción de pieza 3.6 bajo anestesia local. Sin complicaciones.”
Field: future_planPlanned follow-up treatments or next steps in the treatment plan.Example: “Control en 7 días para evaluar cicatrización. Valorar implante en 3 meses.”
Field: next_visitAutomatically calculated based on selected interval (7 days, 15 days, 1 month, etc.).
Field: observationsAdditional notes, precautions, or special considerations.Example: “Paciente alérgica a penicilina. Se prescribió alternativa.”

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Next Visit Intervals

The system provides pre-defined intervals for scheduling follow-up visits: 
const nextVisitOptions = [
  { value: '', label: 'No requiere' },
  { value: '7', label: 'En 7 días' },
  { value: '15', label: 'En 15 días' },
  { value: '21', label: 'En 21 días' },
  { value: '30', label: 'En 1 mes' },
  { value: '60', label: 'En 2 meses' },
  { value: '90', label: 'En 3 meses' },
  { value: '180', label: 'En 6 meses' },
  { value: '365', label: 'En 1 año' }
];

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Automatic Date Calculation

let finalNextVisit = null;
if (recordFormData.next_visit_interval) {
  const days = parseInt(recordFormData.next_visit_interval);
  const date = new Date();
  date.setDate(date.getDate() + days);
  finalNextVisit = date.toISOString().split('T')[0];
}

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Viewing Medical Records

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History Timeline

Medical records are displayed in reverse chronological order (newest first) on the patient’s History tab:
Medical records timeline view

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Record Display Format

{
  date: "15 Febrero 2026",
  doctor: "Dr. Carlos Soto · Cirugía",
  status: "green",
  statusLabel: "Completado",
  motif: "Dolor intenso en molar inferior izquierdo. 3 días de evolución.",
  diagnosis: "Caries profunda con compromiso pulpar — pieza 3.6",
  treatment: "Extracción de pieza 3.6 bajo anestesia local. Sin complicaciones."
}

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Status Badges

Records can be tagged with status badges:

Completado

Green badge - Treatment completed successfully

Control

Blue badge - Follow-up or control visit

En Tratamiento

Amber badge - Ongoing treatment

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Editing Medical Records

Medical record editing requires the EDIT_MEDICAL_RECORDS permission. Some clinics restrict editing to maintain audit trail integrity.

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Edit Workflow

  1. Locate the record in the History tab
  2. Click the edit button (if permission granted)
  3. Modify necessary fields
  4. Save changes
API Endpoint: 
PUT /api/patients/{patientId}/records/{recordId}

Body: {
  motif?: string,
  diagnosis?: string,
  treatment?: string,
  future_plan?: string,
  next_visit?: string,
  observations?: string
}

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Anamnesis Integration

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Medical History Form

The Anamnesis (medical history questionnaire) complements clinical records:
  • Personal medical history: Chronic conditions, surgeries, medications
  • Family medical history: Hereditary conditions
  • Habits: Smoking, alcohol, oral hygiene
  • Vital signs: Blood pressure, heart rate, temperature
Anamnesis is typically filled out once during initial patient registration and updated periodically.

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Anamnesis Permissions

VIEW_ANAMNESIS

View the patient’s medical history questionnaire.

EDIT_ANAMNESIS

Create or modify the patient’s anamnesis form.

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Document Attachments

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Uploading Files

Medical records can include attachments:
  • X-rays and radiographs
  • Lab results
  • Consent forms
  • Treatment photos
  • External reports

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Files Database Schema

CREATE TABLE patient_files (
    id INT AUTO_INCREMENT PRIMARY KEY,
    patient_id INT NOT NULL,
    name VARCHAR(255) NOT NULL,
    file_type VARCHAR(50),
    file_size INT,
    file_url VARCHAR(255) NOT NULL,
    upload_date TIMESTAMP DEFAULT CURRENT_TIMESTAMP,
    FOREIGN KEY (patient_id) REFERENCES patients(id) ON DELETE CASCADE
);

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File Management Permissions

VIEW_ATTACHMENTS

View uploaded files in the patient’s Files tab.

UPLOAD_ATTACHMENTS

Upload new documents and images to patient records.

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API Reference

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List Medical Records

GET /api/patients/{patientId}/records

Response: {
  success: true,
  records: [
    {
      id: number,
      patient_id: number,
      doctor_id: number,
      doctor_name: string,
      doctor_specialty: string,
      record_date: string,
      motif: string,
      diagnosis: string,
      treatment: string,
      future_plan: string,
      next_visit: string | null,
      observations: string
    }
  ]
}

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Create Medical Record

POST /api/patients/{patientId}/records

Body: {
  motif: string,
  diagnosis: string,
  treatment: string,
  future_plan?: string,
  next_visit?: string,
  observations?: string
}

Response: {
  success: true,
  record_id: number
}

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Update Medical Record

PUT /api/patients/{patientId}/records/{recordId}

Body: { /* Same as create */ }

Response: {
  success: true,
  message: 'Record updated'
}

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Permissions Summary

Module: ClínicoAccess to view patient medical records and treatment history. Essential for continuity of care.
Module: ClínicoCreate new clinical records after patient consultations. Typically restricted to doctors.
Module: ClínicoModify existing clinical records. May be restricted for audit compliance.

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Best Practices

1

Document Immediately

Record clinical notes during or immediately after the consultation while details are fresh.
2

Be Specific

Use precise dental terminology (e.g., “pieza 3.6” for specific teeth) and detailed descriptions.
3

Note Allergies

Always cross-reference with patient allergies before prescribing medications.
4

Plan Follow-ups

Use the next_visit field to ensure patients return for necessary follow-up care.
5

Complete All Fields

Fill in motif, diagnosis, and treatment for comprehensive records that support continuity of care.
6

Review History

Before creating a new record, review previous records to understand treatment context.

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Regulatory Compliance

Medical records are legal documents. Ensure all entries are:
  • Accurate and truthful
  • Timestamped automatically by the system
  • Attributed to the treating doctor
  • Comprehensive and professionally written
The system automatically logs:
  • Record creation timestamp
  • Doctor ID (who created the record)
  • Patient ID (who the record belongs to)
This audit trail ensures regulatory compliance and supports medico-legal requirements.

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