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vet 2050 sp24 > Animal Care > Flashcards

Animal Care Flashcards

1
Q

What information can be included in a patient ID?

A

The name of the animal, any electronic ID (microchip), signalment (species, breed, age, gender, reproductive status), color, and distinctive markings (ear notches, scars, tail docking, etc.)

Student #11, JM
McCurnin 10th edition, page: 80

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2
Q

According to McCurnin, where is non-measurable information and measurable information placed in a SOAP?

A

Non-measurable information is categorized as subjective (ex. presenting complaint). Measurable information is categorized as objective (ex. capillary refill time).

Student #11, JM
McCurnin 10th edition, page: 86-87

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3
Q

What are the categories of physiologic need (ranked in order of priority)?

A
  1. Oxygenation
  2. Critical safety and/or severe pain
  3. Hydration
  4. Elimination
  5. Nutrition
  6. Noncritical safety
  7. Chronic pain or mild-to-moderate acute pain
  8. Activity
  9. Utility

Student #11, JM
McCurnin 10th edition, page: 92

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4
Q

What are some technician assessments related to the physiologic need of hydration?

A

Hypervolemia and hypovolemia

Student #11, JM
McCurnin 10th edition, page: 92

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5
Q

What are two purposes that logs serve?

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

Student #11, JM
McCurnin 10th edition, page: 95

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6
Q

What is the purpose of the medication administration/order record?

A

The MAOR may be used to ensure that hospitalized patients are given treatments, diagnostic tests, and diet as requested by the attending veterinarian.

Student #10, AM
McCurnin 10th edition, page: 88

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7
Q

How can veterinary technicians ensure that owners have all information necessary to continue prescribed home care and monitoring of their pet?

A

Provide a clear, concise summary of the pet’s illness, prognosis, and treatment during hospitalization, including discharge instructions written in simple language.

Student #10, AM
McCurnin 10th edition, page: 91

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8
Q

When does assessment of the patient begin?

A

Assessment of the patient begins from a distance (before the cage/stall door is opened).

Student #10, AM
McCurnin 10th edition, page: 90

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9
Q

Regardless of how medications and supplies needed for a specific patient are stored, what is one important thing that must always be done to identify them?

A

Clearly label medications and supplies using the patient’s name, signalment, and owner information.

Student #10, AM
McCurnin 10th edition, page: 91

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10
Q

What are the interventions developed for technician evaluations known as in the patient SOAP?

A

The plan, which is the technician care plan for the patient that will hopefully restore patient comfort and well-being.

Student #10, AM
McCurnin 10th edition, page: 87

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11
Q

What is a critical component of excellent veterinary care and a prudent responsibility of well managed and successful veterinary practices office wise?

A

A thorough, comprehensive, accurate medical record

Student #6 MH
Mccurnin’s 10th edition, page 72

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12
Q

What does VCPR stand for?

A

Veterinarian client patient relationship

Student #6 MH
Mccurnin’s 10th edition, page 74

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13
Q

What is a notation?

A

A notation is any upcoming information that is entered in the progress notes but is independent of the SOAP notes.

Student #6 MH
Mccurnin’s 10th edition, page 88

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14
Q

What does SOVMR stand for and what is it?

A

-SOVMR stands for source oriented veterinary medical record.

-It is patient information that is organized by subject matter. For example, laboratory reports may be kept separate from progress notes which are written in chronological order.

Student #6 MH
Mccurnin’s 10th edition, page 80

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15
Q

What does POVMR stand for and what does it provide?

A

-POVMR stands for problem oriented veterinary medical record.

-It provides organization about information in the medical record by grouping the problems and each problem is separately addressed.

Student #6 MH
Mccurnin’s 10th edition, page 80

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16
Q

What’s are EMRs?

A

Electronic Medical Records

DM,12, McCurnin 10th Ed. Pg. 73

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17
Q

What are the two purposes of a medical record?

A

Primary: medical care based
Secondary: business and legal based

DM,12, McCurnin 10th Ed. Pg. 74

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18
Q

Most common deficit cited by state veterinary examining boards

A

Incomplete medical records

DM,12, McCurnin 10th Ed. Pg. 75

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19
Q

Why is a single line crossing out a mistake not acceptable?

A

Any erasure or blotting out may suggest tampering with the record and and could render the document inadmissible in a court of law

DM,12, McCurnin 10th Ed. Pg. 78

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20
Q

Absence of WNL or NSF is understood as

A

The system was not examined

DM,12, McCurnin 10th Ed. Pg. 82

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21
Q

What are the conditions of a VCPR?

A

13 TN McCurnin 10th Ed

-The veterinarian has assumed responsibility for making clinical judgements regarding the health of the animal and the need for medical treatment, and the client has agreed to follow.
-The veterinarian has recently seen and personally acquainted with the keeping and caring of the animal by virtue of an examination.
-The veterinarian is readily available and has arranged for emergency coverage evaluation in the event of adverse reactions.
-The veterinarian provides oversight of treatment, compliance, and outcome

pg 75

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22
Q

Methods of formatting a medical record fall into three main categories:

A

13 TN McCurnin 10th Ed

-Source-oriented veterinary medical record
-Problem-oriented veterinary medical record
-A combination of the both

pg 79

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23
Q

What does a master problem list entail?

A

13 TN McCurnin 10th Ed

The list includes the major medical disorders experienced by a patient during its lifetime

pg 85

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24
Q

What does a working problem list ential?

A

13 TN McCurnin 10th Ed

The list includes priority health issues that help the veterinary health team in working through the current health problems the patient is facing

pg 85

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25
Q

How often should medical records be reviewed within the hospital to determine if file purging is necessary?

A

13 TN McCurnin 10th Ed

At least once per year

pg 100

26
Q

What are the advantages of electronic medical records?

A

Improved legibility, increased speed of access to data, and ease of use by multiple users at the same time.

TM, #7, McCurnin’s (electronic version) 10th ed. Location 5582 of 67848 (1 out of 5 cards)

27
Q

What is achieved when using standardized exam notes?

A

Consistency and more complete records.

TM, #7, McCurnin’s (electronic version) 10th ed. Location 5582 of 67847 (2 out of 5 cards)

28
Q

What are some advantages to paper records?

A

They do not require a power source, are not subject to operating system updates, and will not break if dropped.

TM, #7, McCurnin’s (electronic version) 10th ed. Location 5671 of 67847 (3 out of 5 cards)

29
Q

What are some disadvantages to paper records?

A

They can be readily misplaced, can only be accessed by one person at a time, or contain inconsistently formatted or illegible entries.

TM, #7, McCurnin’s (electronic version) 10th ed. Location 5671 of 67847 (4 out of 5 cards)

30
Q

What is a database?

A

It is a collection of all available information that would contribute to the diagnostic process of a patient when originally seen for a particular problem.

TM, #7, McCurnin’s (electronic version) 10th ed. Location 5132 of 67847 (5 out of 5 cards)

31
Q

Why are Consent and Authorization forms so important?

A

In keeping with the doctrine of informed consent, completed authorization forms provide veterinary practices with legal evidence that the owner agreed to pursue a particular course of action.

Student #3, AF
McCurnin 10th Edition page: 76
Card 1

32
Q

Who by law is the owner of medical records?

A

Veterinary medical records are the property of the Veterinary practice and its owners. The client is not by law, the owner of the medical record. The client may make a written request at any time for a copy of the pet’s medical records.

Student #3, AF
McCurnin 10th edition page 78
Card 2

33
Q

Why is it important when discharging patients that owners have all the necessary information to take home their pet?

A

It is important to discharge patients in a fashion that ensures a desirable outcome for the patient and the owner. Veterinary Technicians need to ensure that owners have the necessary information and resources to continue any prescribed home care and home monitoring of their pet.

Student #3, AF
McCurnin 10th edition page: 91
Card 3

34
Q

What is a MAOR and what does it ensure?

A

The MAOR or Medication administration/order record or also known as ward treatment sheet, is used to ensure that hospitalized patients are given treatments, diagnostic tests, and diet as requested by the attending veterinarian.

Student #3, AF
McCurnin 10th edition page 88
Card 4

35
Q

What is documented in Hospitalized Patient records daily?

A

Each separate problem is named and described in the initial plan in progress notes by using the SOAP format. If an animal is hospitalized, ongoing daily management of the patient is also documented in a medical record or progress note.

Student #3, AF
McCurnin 10th Edition page 85
Card 5

36
Q

What are the primary (medical care based) functions of a medical record?

A

4 JG

Identification of correct patient and client
Documentation and support of diagnostic procedures, diagnoses, prognoses, and treatment plans
Supports continuity of care
Supports communication between health care team members and the client
Personalizes the VPCR

Bassert, J. M., Beel, A. D., & Samples, O. M. (2021, March 25). McCurnin’s clinical textbook for Veterinary Technicians and nurses. McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses - 10th Edition. (p.74)

37
Q

What are the secondary (business and legal based) functions of a medical record?

A

4 JG

Billing verification
Supports business analysis (income, budgeting, staffing)
Supports inventory maintenance marketing strategy
Supports hospital and individual accreditation
Serves as a legal document
Supports research (case studies, registries and databases, and education)

Bassert, J. M., Beel, A. D., & Samples, O. M. (2021, March 25). McCurnin’s clinical textbook for Veterinary Technicians and nurses. McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses - 10th Edition. (p.74)

38
Q

Why would cage cards and patient identification be important?

A

Cage cards allow the team to quickly identify the patient and their reson for being in the clinic.
#1 CE
McCurnin 10th edition pg 91

39
Q

What are some examples of Veterinary Management Software used today?

A

Some examples of Veterinary Management Software used today include; AVImark, eVet, Idexx Neo and Cornerstone.
#1 CE
McCurnin 10th Edition pg 73

40
Q

What is a disadvantage to electronic medical records?

A

A disadvantage to electronic medical records is that without power you are unable to access records. However, besides that reason, electronic records have many more advantages than paper records.
#1 CE
McCurnin 10th Edition pg 92

41
Q

What is a Numeric Filing System?

A

In Numeric Filing System, each client is geven a number, each digit in the number is a different color. Files are then shelved numerically from lowest to highest.
#1 CE
McCurnin 10th Edition pg 100

42
Q

What does File Purging entail?

A

File Purging essentially is when files should be deletes or shredded aftewr they are no longer in use or are needed. These usually pertain to inactive records of 8yrs or older.
#1 CE
McCurnin 10th Edition pg 100

43
Q

Large animal ambulatory vets are often responsible for food animals and entire herds. How do they manage medical records in this situation?

A

4 JG

Immunizations and reproductive histories are maintained for the group however, individual records are generated for the animals that have undergone special surgical or treatment procedures.

Bassert, J. M., Beel, A. D., & Samples, O. M. (2021, March 25). McCurnin’s clinical textbook for Veterinary Technicians and nurses. McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses - 10th Edition. (p.101)

44
Q

What type of information qualifies as previous history information?

A

4 JG

Origin: animal’s birthplace and date
Preventative medicine program: immunizations, parasitic control, dental care program, ear care program, spaying/neutering, and exercise program
Behavior: usual disposition and temperament, unusual behavior events
Environment: kept indoors or outdoors, presence of other pets or humans in the home, level of exposure to non-family-owned pets, travel history
Nutritional history: current weight, daily diet, and weight changes
Known allergies and reactions: atopy, food, contact with substances, medications, blood transfusions
Reproduction: neutered, estrous cycles, when bred, number of litters
Previous conditions: medical illness, trauma, surgical operations
Medications, treatments, and responses
Prior referral history

Bassert, J. M., Beel, A. D., & Samples, O. M. (2021, March 25). McCurnin’s clinical textbook for Veterinary Technicians and nurses. McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses - 10th Edition. (p.74)

45
Q

What type of information qualifies as recent history information?

A

4 JG

Presenting complaint and circumstances
Date when the patient was last normal
Location and character of the problem, such as quality, severity, onset, duration, time of day, frequency, triggers, associated problems, and progression
Current medications
Treatment efforts if any
Comments and concerns of the owner
Current diet
Recurrent changes in the environment, household schedule, or pets/humans in the household
FAS score (fear, aggression, stress)
Information from previous or referring physician

Bassert, J. M., Beel, A. D., & Samples, O. M. (2021, March 25). McCurnin’s clinical textbook for Veterinary Technicians and nurses. McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses - 10th Edition. (p.82)

46
Q

What is problem-oriented veterinary medical record (POVMR)?

A

-An organized approach to clinical veterinary care in that information in the medical record is grouped by problems, and each problem is addressed separately.

Student #2, AF
McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses – 10th Edition (Chapter 3, Page 80)

47
Q

What are components that make up a signalment?

A
  • Name of the animal
  • Any electronic ID (microchip or tattoo number)
  • Species
  • Breed
  • Gender
  • Reproductive status (intact, spayed, neutered, pregnant)
  • Age
  • Color
  • Distinctive markings (ear notches or cropping, scars, tail docking)

Student: #2, AF
McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses – 10th Edition (Chapter 3, Page 80)

48
Q

What is a master problem list/diagnostic list?

A

The major medical disorders experienced by a patient during its lifetime.

Student: #2, AF
McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses – 10th Edition (Chapter 3, page 85)

49
Q

What is included under “Objective” patient information?

A

All quantifiable information such as vital signs, test results, capillary refill time, and dehydration indictors.

Source: #2, AF
McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses – 10th Edition (Chapter 3, page 90)

50
Q

What are the purposes of logs (there are 2)?

A
  • Provide additional documentation for legal support.
  • Provide data for quick analysis and retrospective studies.

Student: #2, AF
McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses – 10th Edition (Chapter 3, page 95)

51
Q

Inactive records may be removed from storage and shredded after ____ years

A

8 years.

JM #8
McCurnin’s 10th Ed
Pg 100

52
Q

Illegible records are not only unprofessional but can prove _____ in a court

A

8 JM

Indefensible

McCurnin’s 10th Ed
pg 97

53
Q
A
53
Q

True or false? A discontinued medication should be erased from the medical record

A

False. A discontinued medication should be noted in the record as being discontinued, not erased.
#8 JM
McCurnin’s 10th Ed
pg 91

54
Q

what client communications should be included in a patient medical record?

A

emails, phone calls, text messages and verbal communications

rp #9, McCurnin 10th Edition, pg. 92

55
Q

what can we do during a storm to avoid unnecessary loss of equipment and valuable patient information?

A

using surge suppressors and unplugging computers

rp #9, McCurnin 10th Edition, pg. 95

56
Q

how can practices guard against data loss?

A

incorporating backup servers into the practice network and using backup generators/ battery power

rp #9, McCurnin 10th Edition, pg. 95

57
Q

what are the three standards of informed consent?

A
  1. reasonable practitioner standard
  2. reasonable client/patient standard
  3. individual client/ patient standard

rp #9, McCurnin 10th Edition, pg. 75

58
Q

primary functions of the medical record include

A

personalized VCPR
supports communication between healthcare team and client
supports continuity of care

rp #9, McCurnin 10th Edition, pg. 74

59
Q

secondary functions of the medical record include

A

supports research
supports hospital and individual accreditation
supports maintenance marketing strategy

rp #9, McCurnin 10th Edition, pg. 74

vet 2050 sp24 (10 decks)

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