EM-HCP-08 · Subject model · W-IND
Clinical document and record entry
An authored clinical document or record entry, such as a note, a discharge summary or a report, with its author, attestation, status, amendments and medical record retention. Generic document management and terminology are separate contours.
Partially published; research continues
Claude: initial-industry-contour-and-card-supplement; Grok: not-started.
Published results
The independent second-provider study, fixtures and the full research protocol remain open. Runtime promotion is governed by the package allocation holds.
Subject boundary and candidate types
- ClinicalDocument
- DocumentSection
- Attestation
- Amendment
- DocumentStatus
Deep research questions
- How is an amendment recorded so that the original remains readable?
- When does a document become part of the legal medical record?
- How are structured entries and narrative text kept consistent?
Verifiable invariants
- A signed document is never edited, only amended or replaced
- Each document references its patient, encounter and author
- An amendment states its reason and author
End-to-end acceptance scenario
For a synthetic admission, draft and sign a discharge summary, amend it with a reason, share it with another provider, and show both versions with their status.
Negative case
A discharge summary is edited after signing to correct a medication, and the earlier version sent to the family doctor is lost.
Approaches to compare
- HL7 FHIR: Composition and DocumentReference resources
- HL7 CDA and openEHR compositions
- IHE XDS: cross-enterprise document sharing
Candidates in the live catalogue
- WM-REC-001 · Document / Record · 0.3.0-research.1 · installable
Semantic fit requires boundary research; a published model does not by itself complete this card. - WM-REC-002 · Report / Statement · 0.3.0 · not installed automatically
Semantic fit requires boundary research; a published model does not by itself complete this card.
Result requirements
Every card is executed together with the full research contract: definitions, fields and cardinalities, lifecycle, sources, data mastership, rights, the five object facets, at least eight invariants, positive and negative examples, dependencies, migration and applicability limits.