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VET 2050 FA 23 > Animal Care > Flashcards

Animal Care Flashcards

1
Q

What is the importance of MAOR and what does it stand for?

A

Medication Administration/Order Record, used to ensure that hospitalized patients are given treatments, diagnostic tests, and diet as requested by attending veterinarian

ML, Student #6, McCurnin 10th Edition pg.88

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2
Q

Which of the following is the most important technician evaluation?
a) Nutrition
b) Hydration
c) Oxygenation
d) Critical safety/Pain

A

C. Oxygenation

ML, Student #6, McCurnin 10th Edition pg.92

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3
Q

How do ambulatory practices keep medical records of patients?

A

Many carry mobile devices such as a laptop or tablet to prevent loss of papers

ML, Student #6, McCurnin 10th Edition pg. 101

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4
Q

What is the difference between a Master Problem List and a Working Problem List?

A

MPL is essentially a list of final diagnoses generated by the veterinarian, WPL is a dynamic tabulation of clinical problems and symptoms generated by the veterinary and veterinary technician

ML, Student #6, McCurnin 10th Edition pg. 85

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5
Q

What is included in a patient’s medical record?

A

Information regarding patient, client information, lab and imaging results, surgical and anesthetic records, outcomes from studies, referrals, and billing/payment information

ML, Student #6, McCurnin 10th Edition pg. 72

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6
Q

What forms a veterinary client patient relationship?

A

The veterinarian has assumed responsibility for making clinical judgment regardless of the health of the animal and the need for medical treatment, and the client has agreed to follow the veterinarians instructions.
The veterinarian has sufficient knowledge of the animal to initiate at least a general or preliminary diagnosis or the medical condition of the animal.
The veterinarian is readily available or has arranged for emergency coverage for follow up evaluation in the event of adverse reactions or failure of the treatment regimen.
LB, Student #2, McCurnin 9th Edition pg. 78

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7
Q

What is the correct way to correct an error in a hand written medial record:
A: Scratch out the error with indication with name, date and time
B: Erase/blot it out
C: Single line through error with indication of error with name, date and time
D: Single line through error with indication of error with name and date

A

C: Single line through error with indication of error with name, date and time.
LB, Student #2, McCurnin 9th Edition pg. 80

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8
Q

Is the client the owner of the medical records?
A: True
B: False

A

B: False
By law the client is not the owner of the medical records.
LB, Student #2, McCurnin 9th Edition pg. 81

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9
Q

What does SOVMR stand for?

A

Source- orientated veterinary medical record. This is the medical patient information is kept in a subject matter.
LB, Student #2, McCurnin 9th Edition pg. 81

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10
Q

What is the signalment?

A

The information that identifies a individual patient.
LB, Student #2, McCurnin 9th Edition pg. 82

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11
Q

How old can a medical record be, when it is okay to shred or be destroyed?

A

8 years or older

BH, Student #5, McCurnin 9th Ed. Pg. 100

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12
Q

How are Technician SOAPs and Veterinarian SOAPS different?

A

Veterinarian SOAPs are used to find a primary cause and cure for illness, whereas technician SOAPs are used to assess the patient, anticipate future changes and complications, and work with current problems.

BH, Student #5, McCurnin 9th Ed. Pg. 90

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13
Q

What color pen ink is acceptable to use on a medical record?

A

Black or blue

BH, Student #5, McCurnin 9th Ed. Pg 80

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14
Q

What happens if you administered a drug to a patient, but never wrote it down or electronically entered it in the medical record?

A

If it was not written down or electronically entered in the medical record, then it did not happen.

BH, Student #5, McCurnin 9th Ed. pg 80

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15
Q

True or False: A signed estimate by the client for a surgical procedure, is part of a patient’s medical record.

A

True

BH, Student #5, McCurnin 9th Ed. pg 79

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16
Q

What type of medical record does the AAHA insist that practices seeking certification use?

A

(POVMR) Problem-oriented veterinary medical record.

MS, Student #10, McCurnin 10th Ed. pg. 80

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17
Q

What are the components of the Problem-Oriented Veterinary Medical Record (POVMR)?

A
  1. Database: client and patient information, history, physical exam findings, pertinent test results
  2. Master problem list and working problem lists
  3. Initial plan and progress notes
  4. Case summary and discharge instructions

MS, Student #10, McCurnin 10th Ed. pg. 80

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18
Q

What information may be included in a patients previous history?

A

Origin, preventative care, Behavior, Environment, nutritional history, known allergies and reactions, reproduction status, previous illnesses and surgeries, medications, and referral history.

MS, Student #10, McCurnin 10th Ed. pg. 82

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19
Q

What information may be included in a patients recent history?

A

Presenting complaint, date when last normal, location and character of the problem, current medications, treatment efforts, owner concerns/comments, current diet, recent changes in home environment, and FAS score.

MS, Student #10, McCurnin 10th Ed. pg. 82

20
Q

What technician evaluations are included in oxygenation?

A

Altered gas diffusion, altered ventilation, cardiac insufficiency, decreased perfusion, obstructed airway, and risk of aspiration.

MS, Student #10, McCurnin 10th Ed. pg. 92

21
Q

When may an electronic medical record NOT be advantageous over a paper medical record?

A

In the case of power outages or server issues

Student #11 SF
McCurnin’s 9th ed
pg. 101

22
Q

What are some instances in which it is appropriate to release a medical record without consent from the client?

A

-the patient has been diagnosed with a reportable disease
-a court of law has subpoenaed the medical record

Student #11 SF
McCurnin’s 9th ed.
pg 81

23
Q

What is the primary purpose of medical records?
What are some secondary purposes?

A

Primary: to support excellent medical care

Secondary:
-to support business and legal activities
-to support research

Student #11 SF
McCurnin’s 9th ed.
pg 78

24
Q

What are some examples of procedures that are likely to be disputed by clients if informed consent is not ensured?

A

Euthanasia, high-risk procedures, expensive diagnostics

Student #11 SF
McCurnin’s 9th ed
pg 79

24
Q

Q
True or false? Financial information/billing records are part of the medical record.

A

True

Student #11 SF
McCurnin’s 9th ed.
pg 83

25
Q

Are phone conversations with clients considered informed client consent and part of the medical record?

A

Yes, communications with clients should be documented and summarized in the medical record.

Student #4, EKH, McCurnins 9th ed. pg. 79

26
Q

Can the state board of veterinary medicine impose fines if a complaint or lawsuit is filed against a veterinary technician if a medical record is incomplete or inaccurate?

A

Yes, an incomplete medical record can be construed as substandard care or professional incompetence and the state board may impose stiff fine.

Student #4, EKH, McCurnins 9th ed. pg 79

27
Q

What is one pro and one con of the SOVMR?

A

Con: lacks detailed documentation, individual problems are difficult to monitor, physical exams, diagnostic imaging, etc. are in different areas of medical record and may be difficult to find. Pro:

Student #4, EKH, McCurnins 9th ed. pg 81

28
Q

T or F: Computers and monitoring equipment should be unplugged during lightening storms to prevent loss of patient information?

A

True. Using surge protectors and unplugging computers during lightening storms can prevent loss of patient information and equipment.

Student #4, EKH, McCurnins 9th ed. pg 101

29
Q

What is a notation and where is it entered in the medical record?

A

A notation is incoming information, such as communication with the animal’s owner, that is independent of the SOAP.

Student #4, EKH, McCurnin 9th ed. pg 93

30
Q

Which section of a SOAP is when the technician uses critical thinking to generate a list of patient evaluations that reflect the animal’s physical, psychological, social, and environmental conditions?

A

Assessment

CP Student #9 McCurnin 9th Ed. Pg. 92

31
Q

What is the purpose of cage/stall cards?

A

To identify the patient, reason for hospitalization, and sometimes hospital division that is treating the patient

CP Student #9 McCurnin 9th Ed. Pg. 97-98

32
Q

Why is it important to discuss discharge information with the owner?

A

Reviewing discharge information with the owner helps in directly educating the owner about the disease process, complications, and take-home instructions. It also offers an opportunity for the client to ask questions and ask for clarification.

CP Student #9 McCurnin 9th Ed. Pg. 98

33
Q

What are the 2 purposes of logs?

A
  1. To provide additional documentation for legal support
  2. To provide data for quick analysis and retrospective studies

CP Student #9 McCurnin 9th Ed. Pg. 103

34
Q

T/F: It is practical for food animal veterinarians who treat herds of livestock to keep individual records for every animal treated

A

False, it’s more practical to keep a record for each herd as a whole

CP Student #9 McCurnin 9th Ed. Pg. 104

35
Q

If a client refuses treatment should it be included in their records?

A

Yes
Student #8 MKM McCurnin ed. 10th pg. 223

36
Q

What are the 3 standards that determined informed consent?

A
  1. Reasonable practitioner standard-requires disclosure of all fact the doctor believes material to the particular client
  2. Reasonable client/patient standard-requires disclosure of all risks to a reasonable, prudent person in the clients position
  3. individual client/patient standard- requires determination of what risks are material to the particular client being addressed and to disclose those risks.
    Student #8 MKM McCurnin ed. 10th pg. 224
37
Q

Why is it important is have wnl or nsf noted on physical exam

A

It implies that the system was not examined
Student #8 MKM McCurnin ed. 10th pg. 239

38
Q

When are records consider inactive?

A

4 years
Student #8 MKM McCurnin ed. 10th pg. 273

39
Q

What should you do if you misplace a record?

A

Start a new one and request information/copies of lab findings, pathology reports, and radiographs
Student #8 MKM McCurnin ed. 10th pg. 274

40
Q

What is a good way to ensure a client has hear/read and understood discharge instructions following a procedure?

A

Including a place for the client to sign once the discharge instructions have been reviewed.

Student #1 MA McCurnin pg. 91-92

41
Q

What is the use of a laboratory diagnostic flow sheet?

A

It shows all the recorded values of diagnostics performed for a particular patient over time.

Student #1 MA McCurnin pg. 85

42
Q

Are anesthetic drugs given to a hospitalized patient included in the patient’s treatment record?

A

No, these should be recorded separately in an aesthetic record.

Student #1 MA McCurnin pg. 91

43
Q

What is the number one priority physiologic need when assessing technician evaluations for patients?

A

Oxygenation

Student #1 MA McCurnin Pg. 92

44
Q

What is the AAHA standard for storage of paper medical records?

A

An individual medical record should be kept for each patient in standard letter-sized folders.

Student #1 MA McCurnin pg 97

VET 2050 FA 23 (10 decks)

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