VMS

Record Additional Clinical Observation

US-002-01-03-01-FE — Frontend¶

User Story

As a veterinarian, I want to enter additional clinical observations in free text so that I can record findings that are not covered by predefined examination markers.

Frontend Requirements¶

The screen shall provide:

• Free-text clinical notes field.
• Clear label.
• Multi-line input.
• Save with examination.
• Edit before consultation completion.
• Character limit defined by product/technical team.

Acceptance Criteria¶

AC-01

Doctor can enter free-text clinical observations.

AC-02

Text remains associated with the current consultation.

AC-03

Text is not lost when navigating between consultation sections.

AC-04

Doctor can review the note before completing the consultation.

Out of Scope¶

• AI correction of doctor's notes.
• Automatic interpretation.
• Automatic diagnosis.
• Voice-to-text unless separately approved.

US-002-01-03-01-BE — Backend¶

Backend shall:

• Store clinical notes.
• Associate notes with patient.
• Associate notes with consultation/visit.
• Store author.
• Store created timestamp.
• Store updated timestamp.
• Maintain historical record according to audit requirements.

Acceptance Criteria¶

AC-01

A note cannot be stored against the wrong patient.

AC-02

A note cannot be stored against the wrong consultation.

AC-03

Author and timestamp are recorded.

AC-04

Updating the note does not create ambiguity about its latest version.