4 – Problem-Oriented Veterinary Medical Records

Question 1

What is the primary purpose to have a comprehensive record of a patients medical care?

Answer 1

• Natural flow
• Organization
• Provides documentation of all treatments, and communication, etc.
• Essential element in continuity of healthcare delivery for the patient

Question 2

What is the secondary purpose to have a comprehensive record of a patients medical care?

Answer 2

• Serves as a LEGAL RECORD
  o Majority=provincial or local licensing and disciplinary body
  o Minority=court proceedings

Question 3

Generating the medical record: general rules

Answer 3

• Complete but concise
• Legible and written in blue or black ink
• Written or typed in a TIMELY fashion
• Need to include only pertinent info
• Written in professional language
• Cleary ID the patient and owner on all forms
• Each entry signed and dated

Question 4

Managing the medical record

Answer 4

• *they are the PROPERTY of the practice owner
• Original record needs to be retained at practice for at least 5 years
• Ethically: info within all vet med records is considered privileged and confidential

Question 5

What are the 4 components of POVMR?

Answer 5

1. Data base collection
   a. History and physical examination
2. Problem ID
3. Plan formulation
4. MR documentation, assessment and follow-up

Question 6

Initial data base: history and PE

Answer 6

• Signalment (species, age, sex, breed)
• Presenting complaint
• Complete medical history
• Findings from a through physical exam
• Results of any specialized exams performed
  o Ortho, neurological, nutritional

Question 7

Problems and DDx lists

Answer 7

• Problem: any abnormality that may require management
  o List in order of importance and diagnostic value
• Prioritize differentials for each problem recorded
• *splitting or lumping

Question 8

When is splitting a problem list good?

Answer 8

• Different systems
• Different time of onset and clinical course
• Uncertain or not know to be a secondary to primary problem

Question 9

When is lumping a problem list good?

Answer 9

• Same system
• Same time of onset and clinical course
• Apparently secondary to primary problem

Question 10

What are the 3 types of plans that need to be accounted for in the initial summary?

Answer 10

1. Diagnostic plans
2. Therapeutic plans
3. Client education plans

Question 11

What is included in the diagnostic plan?

Answer 11

• Formulation of a list of Dx to help rule in or ule out DDx
• Ex. intent to perform blood work or imaging
• Ex. taking additional more specific history
• Ex. recheck and monitor PE findings or certain parameters

Question 12

What are the 4 broad treatment plan categories?

Answer 12

1. Specific
2. Supportive
3. Symptomatic
4. Palliative

Question 13

What is included in the treatment plan?

Answer 13

• Written as accurately and specifically as possible
• Specific drug name(s)
• Specific dose, route of administration, frequency and timing
• *account for patients dietary and fluid needs in your therapeutic plan

Question 14

Client communication plan

Answer 14

• Plans to update the client by telephone, email, text
• Discharge notes!
• Synopsis of all client communications NEEDS to be documented with date, time and signature
• *always update on status, complications that occurred, prognosis and financial

Question 15

Initial assessment

Answer 15

• Summary of initial data base
• Problem list and prioritized list of DDx for each problem
• Plans: what diagnostic tests or initial treatments are provided
• Diagnostic test findings
• Refined problem list

Question 16

Ongoing assessments

Answer 16

• After initial assessment
• SOAP is used to document ongoing assessment

Question 17

What does SOAP stand for?

Answer 17

• S: subjective
• O: objective
• A: assessment
• P: plan

Question 18

SOAPs

Answer 18

• Written for each major problem
• Numbered and titled to correspond to master problem list
• Typically written once a day
• For critical patients in ICU: may need to do it multiple times a day

Question 19

S: subjective data

Answer 19

• New or pertinent history
• Info obtained from clients about meds administered, potential toxin exposure
• *all non-quantitative observations (ex. mental attitude, appetite, water consumption, urination, defecation, activity)

Question 20

O: objective data

Answer 20

• TPR, PE, lab data, radiographic findings
• ABNORMAL lab values should be mentioned and trends indicated
  o normal values only mentioned if helpful in ruling out DDx

Question 21

A: assessment

Answer 21

• significance of new subjective and objective data should be analyzed
• *most important part of daily SOAP
• Should analyze data, not just repeat it
• If have a diagnosis or tentative diagnosis=state it
• If considering still=rank DDx in order
• Provide evidence gathered that may support or reject DDx on current list

Question 22

P: plan

Answer 22

• Actions you want to take to manage the problem/disease
• Update your plans
  o Diagnostic: ‘big picture’
  o Treatment: adjust fluid therapy, medications
  o Client communication: changes in condition, plan of action, financial update

Question 23

Discharge notes

Answer 23

• Prepared to go home with owner and remain an important summary of current visit in medical record
  o Complete but concise
  o MUST be written in terminology a client can understand
• Owner: provides them a summary of what is wrong and instructions for pets homecare
• make sure it is written when medications are next due