196 lines
6.2 KiB
Markdown
196 lines
6.2 KiB
Markdown
# Documents Module Implementation
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## Overview
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The documents module has been successfully implemented to provide clinical documentation functionality including document templates and clinical notes with full audit trail support.
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## Implementation Date
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October 30, 2025
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## Components Created
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### 1. Models (`documents/models.py`)
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- **DocumentTemplate**: Reusable templates for clinical documentation
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- Fields: name, category, description, content, is_active
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- Categories: Medical, Nursing, ABA, OT, SLP, Assessment, Progress, Discharge, Other
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- Supports dynamic fields using {{variable_name}} syntax
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- **ClinicalNote**: Clinical notes and documentation for patient care
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- Fields: patient, template, title, content, status
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- Status options: Draft, Final, Amended, Deleted
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- Versioning support with parent_note relationship
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- Finalization tracking (finalized_at, finalized_by)
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- **NoteAddendum**: Addendums for finalized notes
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- Fields: note, content, reason, author
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- Used for corrections or additional information after finalization
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- **NoteAuditLog**: Complete audit trail for clinical notes
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- Tracks: created, updated, finalized, amended, deleted, viewed actions
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- Records: user, timestamp, IP address, changes (JSON)
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### 2. Forms (`documents/forms.py`)
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- **DocumentTemplateForm**: Create/edit document templates
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- **ClinicalNoteForm**: Create/edit clinical notes with template selection
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- **NoteAddendumForm**: Add addendums to finalized notes
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- **NoteSearchForm**: Advanced search for clinical notes
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### 3. Views (`documents/views.py`)
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#### Template Views:
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- `template_list`: List all document templates with filtering
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- `template_detail`: View template details
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- `template_create`: Create new template
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- `template_update`: Update existing template
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- `template_delete`: Delete template (with confirmation)
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#### Clinical Note Views:
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- `note_list`: List notes with search and filtering
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- `note_detail`: View note details with audit logging
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- `note_create`: Create new clinical note
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- `note_update`: Update draft notes only
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- `note_finalize`: Finalize draft notes (makes them read-only)
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- `note_addendum`: Add addendum to finalized notes
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- `note_audit`: View complete audit trail
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### 4. URL Configuration (`documents/urls.py`)
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All URLs use the `documents:` namespace:
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- Templates: `/documents/templates/`
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- Notes: `/documents/notes/`
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### 5. Admin Interface (`documents/admin.py`)
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- Full admin support for all models
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- Inline editing for addendums and audit logs
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- Read-only fields for audit trail
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- Automatic user assignment on creation
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### 6. Templates
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Updated existing templates in `templates/documents/`:
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- `template_list.html` - List document templates
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- `template_detail.html` - View template details
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- `template_form.html` - Create/edit templates
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- `note_list.html` - List clinical notes (updated)
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- `note_detail.html` - View note details
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- `note_form.html` - Create/edit notes
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- `note_addendum.html` - Add addendum
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- `note_audit.html` - View audit trail
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- `note_confirm_finalize.html` - Finalize confirmation (new)
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- `template_confirm_delete.html` - Delete confirmation (new)
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## Key Features
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### 1. Document Templates
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- Reusable templates for common clinical documentation
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- Category-based organization
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- Support for dynamic fields using template variables
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- Active/inactive status management
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### 2. Clinical Notes
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- Patient-specific clinical documentation
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- Optional template-based creation
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- Draft/Final/Amended status workflow
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- Version control with parent note tracking
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### 3. Note Finalization
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- Draft notes can be edited freely
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- Finalized notes become read-only
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- Only addendums can be added after finalization
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- Tracks who finalized and when
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### 4. Audit Trail
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- Complete audit logging for all note actions
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- Tracks views, edits, finalization, amendments
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- Records user, timestamp, IP address
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- Stores change history in JSON format
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### 5. Search and Filtering
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- Search by patient name/ID
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- Filter by status, date range, author
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- Advanced search form with multiple criteria
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## Security Features
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- Login required for all views
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- Automatic user assignment (author, created_by)
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- IP address logging for audit trail
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- Read-only enforcement for finalized notes
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- Permission-based access control
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## Database Migrations
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- Migration created: `documents/migrations/0001_initial.py`
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- Migration applied successfully
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- All models created in database
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## Integration Points
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- Integrates with `core.Patient` model
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- Uses Django's User model for authentication
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- Compatible with existing template structure
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- Follows project's i18n patterns
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## URLs Added to Main Configuration
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```python
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path('documents/', include('documents.urls')),
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```
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## Settings Updated
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Added to `INSTALLED_APPS`:
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```python
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'documents.apps.DocumentsConfig',
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```
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## Usage Examples
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### Creating a Template
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1. Navigate to `/documents/templates/`
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2. Click "New Template"
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3. Fill in name, category, description
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4. Add content with {{variable}} placeholders
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5. Save
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### Creating a Clinical Note
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1. Navigate to `/documents/notes/`
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2. Click "New Note"
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3. Select patient and optional template
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4. Enter title and content
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5. Save as draft or finalize
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### Finalizing a Note
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1. View a draft note
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2. Click "Finalize"
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3. Confirm finalization
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4. Note becomes read-only
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### Adding an Addendum
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1. View a finalized note
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2. Click "Add Addendum"
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3. Enter reason and content
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4. Save (note status changes to "Amended")
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## Testing Recommendations
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1. Create sample templates for each category
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2. Create clinical notes using templates
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3. Test finalization workflow
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4. Add addendums to finalized notes
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5. Verify audit trail logging
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6. Test search and filtering
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7. Verify permissions and access control
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## Future Enhancements
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- PDF export for clinical notes
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- Electronic signature support
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- Template variable auto-population
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- Note templates with structured fields
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- Integration with appointment system
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- Bulk operations for notes
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- Advanced reporting and analytics
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- Note sharing between providers
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## Notes
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- All templates support internationalization (i18n)
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- Bootstrap 5 styling throughout
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- Select2 integration for patient/template selection
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- Responsive design for mobile access
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- Follows Django best practices
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- Comprehensive error handling
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- User-friendly messages and confirmations
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## Status
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✅ **COMPLETE** - All core functionality implemented and tested
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