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Medical Records

Medical records in VetCarePress capture the clinical history of each patient.

Storage

Medical records are stored as the vcp_medical_record custom post type. Post titles are auto-generated in the format Patient Name — Record Type — Date. Gutenberg is disabled for this CPT; all fields are managed through the classic metabox UI.

Record Types

VetCarePress supports five medical record types:

  1. Clinical Note — general examination notes, visit summaries, and SOAP notes. See Clinical Notes.
  2. Diagnosis — diagnosis records with status tracking (e.g., Tentative, Final). See Diagnoses.
  3. Lab Result — structured laboratory results with per-marker values and reference ranges. See Lab Results.
  4. Medical Imaging — X-rays, ultrasounds, CT scans, MRI, and DICOM files. See Medical Imaging.
  5. Treatment — treatments, procedures, and medications. See Treatments.

Vaccinations are handled separately through the dedicated vcp_vaccination custom post type. See Vaccinations.

Enabling and Disabling Record Types

Each record type can be individually enabled or disabled under Settings > Features. Disabled types will not appear in creation forms or on patient profile tabs.

Badge Colors

Each record type has a customizable badge color used for visual identification on patient profiles and record lists.

Record Structure

Every medical record is linked to a patient and includes:

  • Record type — one of the five types listed above
  • Type-specific fields — conditional fields that appear based on the selected record type
  • Notes — free-text content field
  • File attachment — optional uploaded file (images, PDFs, DICOM files)

Creation Interfaces

Medical records can be created through:

  • WP-Admin — the MedicalRecordMetabox on the record edit screen provides all fields in a classic metabox layout. Select the record type and conditional fields appear.
  • Staff Dashboard — modal forms with type-specific fields, taxonomy search with inline creation, and file upload support. See Staff Dashboard: Medical Records.

Sharing and Notifications

  • Records can be shared via share links, allowing pet owners to view specific records without full portal access. See Sharing & Privacy.
  • Notifications can be configured to alert pet owners when new records are created. See Notifications.

See also: Clinical Notes, Diagnoses, Medical Imaging, Lab Results

Clinical Notes

Clinical Notes

Clinical notes are used for recording general examination findings, visit summaries, and SOAP notes. They provide a free-form way to document patient encounters.

Note Type Taxonomy

Clinical notes are categorized using the vcp_clinical_note_type taxonomy. This allows you to classify notes by purpose or context.

  • Default term: General Examination
  • Additional terms can be created and managed in WP-Admin > Taxonomies
  • Terms can also be created inline when adding a record (see Staff Dashboard below)

Fields

Each clinical note record includes:

  • Note Type — a term from the vcp_clinical_note_type taxonomy
  • Notes — rich text content area for the examination narrative
  • Attachment — an optional file upload (images, PDFs, etc.)

Creating Clinical Notes via WP-Admin

  1. Navigate to VetCarePress > Medical Records > Add New.
  2. In the MedicalRecordMetabox, select Clinical Note as the record type.
  3. Conditional fields for Clinical Note appear:
    • Select or search for a Note Type
    • Enter the Notes content
    • Optionally upload an Attachment
  4. Select the Patient this record belongs to.
  5. Publish the record.

Creating Clinical Notes via Staff Dashboard

  1. Open a patient profile and click "Add Medical Record" in the staff admin banner.
  2. Select Clinical Note from the record type selector.
  3. The Clinical Note form modal appears with:
    • Note Type — Select2 dropdown with taxonomy search and inline creation. Type a new name and select "Add New" to create a term on the fly.
    • Notes — text area for the examination content
    • Attachment — file upload field
  4. Submit the form to create the record.

Viewing Clinical Notes

Clinical notes are displayed on the Clinical Notes tab of the patient profile. Each entry shows:

  • Type badge with the note type label
  • Date and time of the record
  • Content preview
  • View button to access the full record detail

See also: Medical Records Overview, Patient Profiles, Staff Dashboard: Medical Records

Diagnoses

Diagnoses

Diagnosis records allow you to document patient diagnoses with structured status tracking, supporting workflows from initial suspicion through to confirmed findings.

Related Taxonomies

Diagnosis records use two taxonomies:

  • vcp_diagnoses — the diagnosis terms themselves (e.g., Diabetes, Hip Dysplasia, Ear Infection). You can create as many terms as needed to match your practice’s diagnostic vocabulary.
  • vcp_diag_status — status terms that track the certainty or stage of a diagnosis (e.g., Tentative, Final). Custom statuses can be added to match your workflow.

Fields

Each diagnosis record includes:

  • Diagnosis Status (required) — a single term from the vcp_diag_status taxonomy
  • Diagnoses (required) — one or more terms from the vcp_diagnoses taxonomy (multi-select)
  • Notes — free-text field for additional clinical context
  • Attachment — an optional file upload

Status Workflow

A typical status workflow progresses from Tentative to Final, though you can define any custom statuses that suit your practice. Each diagnosis record captures a point-in-time status, so the progression is visible across multiple records.

Creating Diagnoses via WP-Admin

  1. Navigate to VetCarePress > Medical Records > Add New.
  2. In the MedicalRecordMetabox, select Diagnosis as the record type.
  3. Fill in the conditional fields:
    • Select a Diagnosis Status
    • Select one or more Diagnoses terms
    • Enter Notes as needed
    • Optionally upload an Attachment
  4. Select the Patient this record belongs to.
  5. Publish the record.

Creating Diagnoses via Staff Dashboard

  1. Open a patient profile and click "Add Medical Record" in the staff admin banner.
  2. Select Diagnosis from the record type selector.
  3. The Diagnosis form modal appears with:
    • Diagnosis Status — Select2 dropdown with taxonomy search and inline creation
    • Diagnoses — multi-select Select2 field with taxonomy search and inline creation
    • Notes — text area
    • Attachment — file upload field
  4. Submit the form to create the record.

Viewing Diagnoses

Diagnosis records are displayed on the Diagnoses tab of the patient profile. Each entry shows:

  • Status badge indicating the current diagnosis status
  • Diagnosis terms listed as labels
  • Notes content
  • Date and time of the record

See also: Medical Records Overview, Patient Profiles, Staff Dashboard: Medical Records

Medical Imaging

Medical Imaging

Medical imaging records store and display diagnostic images such as X-rays, ultrasounds, CT scans, and MRI scans. VetCarePress includes a built-in DICOM viewer for viewing .dcm files directly in the browser.

Imaging Type Taxonomy

Images are categorized using the vcp_imaging_type taxonomy. Common terms include:

  • Radiograph (X-ray)
  • Ultrasound
  • CT (Computed Tomography)
  • MRI (Magnetic Resonance Imaging)

Additional terms can be created to match your practice’s imaging capabilities.

Fields

Each imaging record includes:

  • Imaging Type — a term from the vcp_imaging_type taxonomy
  • Notes/Findings — free-text field for radiologist notes or clinical observations
  • DICOM file — upload a .dcm or .zip file for the built-in DICOM viewer
  • Attachment — standard image files (JPEG, PNG) or PDFs

DICOM Viewer

VetCarePress includes a built-in DICOM viewer (lib/dicom-viewer-core/) that renders .dcm files directly in the browser. The viewer supports:

  • Window/level adjustment — modify brightness and contrast for optimal viewing
  • Zoom — magnify areas of interest
  • Pan — navigate across the image

DICOM Download

DICOM file downloads can be enabled or disabled via the vcp_allow_dicom_download setting under Settings > Features (enabled by default).

Creating Imaging Records via WP-Admin

  1. Navigate to VetCarePress > Medical Records > Add New.
  2. In the MedicalRecordMetabox, select Imaging as the record type.
  3. Fill in the conditional fields:
    • Select an Imaging Type
    • Enter Notes/Findings
    • Upload a DICOM file if applicable
    • Optionally upload a standard Attachment
  4. Select the Patient this record belongs to.
  5. Publish the record.

Creating Imaging Records via Staff Dashboard

  1. Open a patient profile and click "Add Medical Record" in the staff admin banner.
  2. Select Imaging from the record type selector.
  3. The Imaging form modal appears with:
    • Imaging Type — Select2 dropdown with taxonomy search
    • Notes/Findings — text area
    • DICOM file upload — accepts .dcm and .zip files
    • Attachment — standard file upload
  4. Submit the form to create the record.

File Security

All uploaded files are stored in a protected directory (wp-content/uploads/vetcarepress/) with scrambled filenames. Files are served through a permission-gated FileServer that verifies access rights before delivering content. Direct URL access to the files is blocked.

Viewing Imaging Records

Imaging records are displayed on the Imaging tab of the patient profile. Each entry shows:

  • Type badge with the imaging type label
  • DICOM viewer rendered inline for .dcm files
  • Attachment thumbnails for standard image files
  • Notes and findings content
  • Date and time of the record

See also: Medical Records Overview, Patient Profiles, Sharing & Privacy

Lab Results

Lab Results

Lab result records provide structured storage for laboratory test data, including per-marker values with reference ranges and automatic status computation. VetCarePress supports three parallel lab systems for different specimen types.

Three Lab Systems

VetCarePress supports three independent lab systems — Bloodwork, Urine, and Stool — each with its own set of panels and markers. See Lab Configuration for setup details.

Fields

Each lab result record includes:

  • Lab Type (required) — a term from the vcp_lab_type taxonomy
  • Structured marker data — conditional panel UI that appears based on the lab type’s CPT pair
  • Free-text results — optional narrative results field
  • Notes — additional clinical observations
  • Attachment — optional file upload (e.g., lab report PDF)

Structured Marker Entry

When creating lab results through the Staff Dashboard, the structured marker interface provides:

Loading a Panel

  1. Select a panel from the species-filtered dropdown.
  2. Click "Load Panel" to populate the marker table with all markers from that panel, pre-filled with default units and reference ranges.

Adding Individual Markers

  • "Add Marker" — select and add a single marker from the taxonomy
  • "Add Custom Marker" — add a blank custom row for markers not in the system

Marker Table

Each row in the marker table contains:

  • Name — the marker name
  • Value — the measured result (numeric input)
  • Unit — the measurement unit
  • Reference Range — minimum and maximum values defining the normal range
  • Status — automatically computed based on the value and reference range
  • Delete — remove the marker from the record

Status Computation

Marker status is computed automatically based on the entered value and reference range:

  • Low (red) — value is below the minimum reference range
  • Normal (green) — value falls within the minimum to maximum range
  • High (red) — value exceeds the maximum reference range
  • Unknown — no reference range is defined for the marker

Creating Lab Results via WP-Admin

  1. Navigate to VetCarePress > Medical Records > Add New.
  2. In the MedicalRecordMetabox, select Lab Result as the record type.
  3. Select a Lab Type. The marker entry UI appears based on the CPT pair.
  4. Load a panel or add markers individually, then enter values.
  5. Add Notes and upload an Attachment as needed.
  6. Select the Patient and publish the record.

Creating Lab Results via Staff Dashboard

  1. Open a patient profile and click "Add Medical Record" in the staff admin banner.
  2. Select Lab Result from the record type selector.
  3. Choose a Lab Type from the dropdown.
  4. Use the panel and marker interface to enter structured results.
  5. Submit the form to create the record.

Viewing Lab Results

Lab results are displayed on the Laboratory tab of the patient profile. Each entry shows:

  • Lab type badge
  • Marker table with values, units, and reference ranges
  • Abnormal values highlighted with color-coded status indicators
  • Notes and attachment links

See also: Medical Records Overview, Lab Configuration, Patient Profiles

Treatments

Treatments

Treatment records document the treatments, procedures, and medications administered to a patient. They use a two-level taxonomy structure to categorize both the type of treatment and the specific treatment performed.

Related Taxonomies

Treatment records use two taxonomies:

  • vcp_treat_type — treatment type categories that classify the nature of the intervention (e.g., Surgery, Medication, Procedure, Therapy)
  • vcp_treatments — specific treatment terms that describe what was done (e.g., Spay/Neuter, Amoxicillin, Dental Cleaning, Fluid Therapy)

Both taxonomies are fully customizable. Add terms that match your practice’s treatment vocabulary.

Fields

Each treatment record includes:

  • Treatment Type (required) — a single term from the vcp_treat_type taxonomy
  • Treatments (required) — one or more terms from the vcp_treatments taxonomy (multi-select)
  • Notes — free-text field for dosage details, procedure notes, or follow-up instructions
  • Attachment — an optional file upload (e.g., post-operative images, discharge instructions)

Creating Treatment Records via WP-Admin

  1. Navigate to VetCarePress > Medical Records > Add New.
  2. In the MedicalRecordMetabox, select Treatment as the record type.
  3. Fill in the conditional fields:
    • Select a Treatment Type
    • Select one or more Treatments
    • Enter Notes as needed (dosage, instructions, observations)
    • Optionally upload an Attachment
  4. Select the Patient this record belongs to.
  5. Publish the record.

Creating Treatment Records via Staff Dashboard

  1. Open a patient profile and click "Add Medical Record" in the staff admin banner.
  2. Select Treatment from the record type selector.
  3. The Treatment form modal appears with:
    • Treatment Type — Select2 dropdown with taxonomy search and inline creation
    • Treatments — multi-select Select2 field with taxonomy search and inline creation
    • Notes — text area for details
    • Attachment — file upload field
  4. Submit the form to create the record.

Viewing Treatment Records

Treatment records are displayed on the Treatments tab of the patient profile. Each entry shows:

  • Type badge with the treatment type label
  • Treatment terms listed as labels
  • Notes content
  • Date and time of the record
  • View and Share buttons (if sharing is enabled)

See also: Medical Records Overview, Patient Profiles, Staff Dashboard: Medical Records

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