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VET 2050 SP 23 > Animal Care and Nursing > Flashcards

Animal Care and Nursing Flashcards

1
Q

What is informed consent?

A

A persons agreement to allow something to happen, such as a medical, diagnostic, or surgical procedures based on full disclosure of facts necessary to make an intelligent decision

Student #6, AF, McCurnin 10th ed. pg. 75

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2
Q

What should consent and authorization forms outline?

A

Specific conditions, risk of procedures, and responsibilities of both parties

Student #6, AF, McCurnin 10th ed. pg. 76

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3
Q

Veterinary medical records are the property of whom?

A

The veterinary practice and its owners

Student #6, AF, McCurnin 10th ed. pg. 78

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4
Q

What are the components of the problem-oriented veterinary medical record

A

Database, master problem list and working problem lists, initial plan and progress notes, case summary and discharge instructions

Student #6, AF, McCurnin 10th ed. pg. 80

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5
Q

MAOR

A

medical administration order record: This is used to insure that the hospidtalized pt were given the tx, dx and diet requested by the veterinarian. This is for the management of hospitalized pt’s.
Student # 20
McCurnin 10th ed. pg. 88

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6
Q

Tech assessments for eliminations

A

Altered urinary production
Bowel incontinence
Constipation
Diarrhea
Self-care deficit
Urinary incontinence
Student # 20
McCurnin 10th ed. pg. 92

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7
Q

Tech assessments for Oxygenation

A

Altered gas diffusion
Altered ventilation
Cardiac insufficiency
Decreased perfusion
Obstructed airways
Risk of aspiration
Student # 20
McCurnin 10th ed. pg. 92

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8
Q

What are the two purposes of logs?

A

1: They provide additional documentation for legal support
2:They provide data for quick analysis and retrospective studies
Student # 20
McCurnin 10th ed. pg. 95

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9
Q

What does AAHA require?

A

Each pt to have there own medical record
Student # 20
McCurnin 10th ed. pg. 100

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10
Q

Which section of the SOAP should measurable data such as laboratory results, temperature, heart rate, respiratory rate, weight, and CRT be noted?

A

The objective section

Student #6, AF, McCurnin 10th ed. pg. 86

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11
Q

Why is it important to house electronic medical records within heavily secured servers?

A

To protect medical records from tampering and risk of loss

Student #11 ML
McCurnin 10th ed. pg. 95

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12
Q

What are some advantages of electronic medical records?

A

Improved legibility, speed of access, ease of use by multiple users, and decreased risk of loss

Student #11 ML
McCurnin 10th ed. pg. 92

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13
Q

What is found in the Plan section of a SOAP done by a vet tech?

A

The plan should include an intervention for each of the assessments outlined, which may include administering meds, client education, and follow-up appointments

Student #11 ML
McCurnin 10th ed. pg. 87

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14
Q

How do SOAPs differ between DVM and vet tech?

A

DVMs seek primary causes and a cure for illness.
Vet techs assess the patient’s physiologic and psychosocial responses to illness and strive to alleviate the responses.

Student #11 ML
McCurnin 10th ed. pg. 86

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15
Q

What is the working problem list?

A

It is a dynamic list of clinical problems and signs. This helps identify and prioritize problems to help formulate interventions.

Student #11 ML
McCurnin 10th ed. pg. 85

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16
Q

What should be included in the discharge papers in simple language that the client can understand?

A

Pets illness, Prognosis, and Treatment

Student #3, SC
McCurnin 10th Edition Page:91

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17
Q

Why are cage cards and patient identification used?

A

To identify the patient and the reason for hospitalization.

Student #3, SC
McCurnin 10th Edition Page:91

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18
Q

Patient name, Species, Breed, Gender, Reproductive status, age, and color is considered as the what?

A

Signalment

Student #3, SC
McCurnin 10th Edition Page:80

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19
Q

Contact information for a client includes what?

A

Mailing address, Home/Cell/Office phone numbers, and email address.

Student #3, SC
McCurnin 10th Edition Page:80

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20
Q

What is the last portion of the SOAP notes?

A

Plan

Student #3, SC
McCurnin 10th Edition Page:87

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21
Q

What components should be included in the patient history?

A

-Origin, preventative medications, behavior, environment, nutritional history, known allergies/reactions, reproduction, previous condition, medications/treatments/responses, and prior referral history.
Student #4, BE, Pg 84

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22
Q

Difference between Master problem list and Working problem list?

A

-Master list refers to anything the P has experienced throughout life while the working list is currently happening to P.
Student #4 BE, Pg 88

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23
Q

Time length considerations prior to purging old files?

A

-Records that have been inactive for 4yrs or longer should be moved to storage but are easily accessible.
-Records inactive for 8yrs or longer can be removed from storage and shredded
Student #4, BE, Pg 100

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24
Q

What are the format options for medical records?

A

-SOVMR -> source- oriented veterinary medical record
-POVMR -> Problem-oriented veterinary medical record
Or a combination of both (digital records utilize both)
Student #4, BE, Pg. 81

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25
Q

What are two exceptions in which a patient’s medical record can be shared without the owner’s permission?

A

-DMV diagnosed a reportable disease required by law
-Court of law subpoena
Student #4, BE, Pg 81

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26
Q

What are progress notes?

A

Chronologically ordered notations are made in the medical record that describe the events of each patient’s exam, diagnosis, and treatment.
Student # 10 AJ
McCurins 10th edition page 81

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27
Q

What is all included in the therapeutic plan?

A

changes in therapy
MAOR
name of medication
time
date
dosage and directions
fluid rate
route administered
frequency
duration of treatment
identification of individuals
Student # 10 AJ
McCurins 10th edition page 83

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28
Q

What should be included in the cautionary notes?

A

slaughter withdraws and milk withholdings for food animals
client communication
client waivers
client phone log
discharge instructions
Student # 10 AJ
McCurins 10th edition page 83

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29
Q

What does WNL stand for?

A

within normal limits
Student # 10 AJ
McCurins 10th edition page 86

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30
Q

What are tech assessments related to hydration?

A

hypervolemia or hypovolemia

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31
Q

What is the most common deficit cited by state veterinary exam boards in investigations of complaints?

A

Incomplete medical records
Student #2 vc
McCurnin 10th ed. pg 75

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32
Q

How should an error in a hard copy medical record be corrected?

A

A single line should be drawn through the mistake and the word “error” written in the margin, along with the correct information. The change is also signed and dated by the person who made the error, with a brief explanation for the correction entered.
Student #2 vc
McCurnin 10th ed. pg 77

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33
Q

What type of medical record style does AAHA endorse and insist on its use in practices seeking AAHA certification?

A

Problem- oriented veterinary medical record (POVMR)
Student #2 vc
McCurnin 10th ed. pg 80

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34
Q

What are ways that records can be lost?

A

Through misfiling, incorret spelling of names, or misplacement.
Student #2 vc
McCurnin 10th ed. pg 100

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35
Q

What are examples of secondary purposes of medical records?

A

Serves as legal evidence of services, used to assess workloads of staff members and maintain inventory.
Student #2 vc
McCurnin 10th ed. pg 74

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36
Q

Is juvenile consent considered legal consent if they are the established caregivers?

A

No, it is not usually considered legal consent.
Student #14 Sp
McCurnin 10th ed. pg 76

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37
Q

Why is previous history important to have?

A

It can help with knowing the animal’s origin, their normal behavior, their nutrition history, if they are inside/outside animals, their nutritional history, any known allergies, previous conditions, reproduction, medications, and referral history are all important things to know.

Student #14 Sp
McCurnin 10th ed. pg 82

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38
Q

Why are physical examination findings important?

A

It can be a key factor to help diagnose the patient and rule out any factors as to what might be wrong with the patient. This is only if note taking is done thoroughly.

Student #14, Sp
McCurnin Ed. 10 pg 82

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39
Q

Why is it important to always put something down like WNL, or NSF on the physical exam findings?

A

The areas that do not have anything written implies that the system was not examined.

Student #14 Sp
McCurnin 10th ed. pg 82

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40
Q

Why is it important to always write with legible handwriting?

A

Illegible writing can impede patient care and can lead to errors in both health care delivery and client communications. They also can be viewed as unprofessional and can be subject a practice to state board review.
Student #14 Sp
McCurnin 10th ed. pg 97

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41
Q

What needs to happen in the event that records are lost?

A

Inform the client of the loss and start a new file. Any copies of lab data, pathology reports, and radiologic information either provided by the veterinarian or the client should be added to the new file.
Student #18 BKS
McCurnin 9th ed. pg. 100

42
Q

Risk of loss is less with digital files, but not zero. What are some ways to protect digital files?

A
  1. Unplug computers or use surge protectors during lightning storms.
  2. Use back up servers to store data at the end of each day
  3. Be prepared with backup generators or battery power in the event of regional blackouts.
    Student #18 BKS
    McCurnin 9th ed. pg 101
43
Q

Complete the following rules of thumb when it comes to the discipline of record keeping.

  1. If it was not written down or electronically entered into the patient’s medical record, _______________________________________________________.
  2. If the writing is illegible, ______________________________________.
  3. If one part of the medical record shows signs of tampering or is inaccurate, _______________________________________________.
A
  1. it did not happen
  2. it was not written down
  3. the integrity of the entire medical record becomes questionable
    Student # 18 BKS
    McCurnin 9th ed. pg. 80
44
Q

Why is it important to initial and date entries in a medical record?

A

Medical records are considered legal evidence or services and procedures. Signing or initialing entries with a date makes it clear in a court of law who authored a particular entry in the medical record
Student # 18 BKS
McCurnin 9th ed. pg. 80

45
Q

Additional information from a referring veterinarian that is not part of the SOAP can be recorded as a _________ in hospitalized patient’s progress notes.

A

notation
Student # 18 BKS
McCurnin 9th ed. pg. 93

46
Q

What does “NSF” stand for?

A

No significant findings
#13 KM
McCurnin 10th ed. pg. 82

47
Q

What does “EMR” stand for?

A

Electronic medical record
#13 KM
McCurnin 10th ed. pg. 73

48
Q

Primary purposes vs. secondary purposes

A

Primary purposes support the patient’s care and include all documentation of diagnoses, prognoses, and treatment. Secondary purposes are not clinically based but include medical information for business, legal and research purposes.
#13 KM
McCurnin 10th ed. pg. 74

49
Q

WHat should be included on each entry in the medical record?

A

A date and time stamp should be included along with signature or initials of who made the entry.
#13 KM
McCurnin 10th ed. pg. 90

50
Q

What does “FAS” stand for?

A

Fear, aggression, stress
#13 KM
McCurnin 10th ed. pg. 82

51
Q

What are the advantages of numeric filling?

A

Fewer filling errors occur because numbers are easier to read and interpret compared with letters, and spelling is not a factor.
Student #8 KH, McCurnin 10th ed. pg. 100

52
Q

Aside from serving as filing aids, what other purpose can colored tabs serve as?

A

Colored tabs can also be applied to files to alert receptionist to specific client-patient issues. Example: reminders of immunizations.
Student #8 KH, McCurnin 10th ed. pg. 99

53
Q

Tech assesments related to Nutrition?

A

Altered oral health, abnormal eating behavior, ineffective nursing, overweight, self-care deficit, underweight, vomitting and/or diarrhea.
Student #8 KH, McCurnin 10th ed. pg 92

54
Q

Tech assesments related to Utility?

A

Aggression, anxiety, client coping deficit, client knowledge deficit, fear, inappropriate elimination, reproductive dysfunction.
Student #8 KH, McCurnin 10th ed. pg 92

55
Q

What should always be included in a MAOR?

A

Pateitns full name, patient ID number, and/or signalment, and any known allergies the patient may have.
Student #8 KH, McCurnin 10th ed. pg. 89

56
Q

What does AAHA stand for?

A

American Animal Hospital Association
Student #9 KJ
McCurnin 10th ed. pg. 73

57
Q

Why should you write or type in black ink when possible?

A

This will improve clarity of images during copying or faxing.
Student #9 KJ
McCurnin 10th ed. pg. 76

58
Q

Should all communication with clients be recorded in the medical record? Including face-to-face, email, and text conversations?

A

Yes. Medical records can be used as legal documentation in court so it is crucial to include all details when applicable.
Student #9 KJ
McCurnin 10th ed. pg. 76

59
Q

What is a consultant in regards to a specialty hospital when working with a patient?

A

These are specialists that are consulted to a case where a specific problem needs to be addressed. Specialty departments include Oncology, Internal Medicine, Behavior, Dermatology, etc.
Student #9 KJ
McCurnin 10th ed. pg. 85

60
Q

What s the master problem list also known as?

A

Diagnosis list
Student #9 KJ
McCurnin 10th ed. pg. 85

61
Q

What is a VCPR?

A

A Veterinarian-Client-Patient-Relationship.
#19 MW
McCurnin 10th ed. pg 75

62
Q

What is the difference between SOVMR and POVMR?

A

SOVMR is organized by subject matter while POVMR is organized by each individual problem the patient is seen for.
#19 MW
McCurnin 10th ed. pg. 80

63
Q

What are two ways to prevent risk of loos of records?

A

Use surge protectors and unplug computers during storms.
#19 MW
McCurnin 10th ed. pg. 95

64
Q

What is another name for the MAOR

A

Ward Treatment Sheet
#19 MW
McCurnin 10th ed. pg. 88

65
Q

How should entries be entered into the EMR?

A

In chronological order by date and time.
#19 MW
McCurnin 10th ed. pg. 73

66
Q

What is the most important diagnostic procedure performed?

A

Physical Exam
Student #16 ER
McCurnin 10th Edition pg 84

67
Q

What must be included in all entries of medical records?

A

The signature or initials of the author, the author’s credentials (CVT, DVM), and the date and time of the entry.
Student #16 ER
McCurnin 10th Edition pg 80

68
Q

Which section of a SOAP should all non-measurable information go?

A

Subjective
Student #16 ER
McCurnin 10th Edition pg 90

69
Q

What is the medication administration/order record (MAOR) sheet used for?

A

Ensure completion of patient treatments, diagnostic tests, and assigned diets
Student #16 ER
McCurnin 10th Edition pg 93

70
Q

Which portion of the SOAP should hypothermia be recorded?

A

Assessment
Student #16 ER
McCurnin 10th Edition pg 92

71
Q

What are the reasons that proper animal restrain is critical to veterinary care?

A

5 SF

Restraint prevents the animal from harming themselves or medical professionals while allowing staff to provide medical care.

McCurnin 9th ed. pg 166

72
Q

What medical tasks are only DVMs allowed to perform? (things that technicians can’t do)

A

5 SF

-diagnosis
-prognosis
-surgery
-prescribing medication

McCurnin 9th ed. pg 14

73
Q

What is the most common form of aggression that animals display towards humans?

A

5 SF

Fear-related aggression

McCurnin 9th ed. pg 140

74
Q

Why should scruffing a cat be a last resort when it comes to restraint?

A

5 SF

A lot of cats react negatively to being scruffed and will begin to resist restraint even more

McCurnin 9th ed. pg 174

75
Q

What are some benefits of having digital medical records over hard copies?

A

5 SF

-improved legibility
-easier/faster to access data
-multiple people can access same record at once
-decreased risk of loss
-large amount of data can be included and properly organized

McCurnin 9th ed. pg 101-102

76
Q

The Institution of Medicine has organized the functions of the medical record into 2 broad categories, known as?

A

1) Primary Purpose
2) Secondary purpose
#1, MA
McCurnin 10th ed. pg. 74

77
Q

The VCPR serves as the foundation of the interactions between whom?

A

Veterinarians, their clients, and their patients
#1, MA
McCurnin 10th ed. pg 75

78
Q

What must be maintained when a VCPR exists?

A

Medical records must be maintained for all patients whom a VCPR exist
#1, MA
McCurnin 10th ed. pg 75

79
Q

Informed consent is generally determined and applied on the basis of what 3 standards?

A

1) Reasonable practitioner standard
2) Reasonable client / patient standard
3) Individual client / patient standard
#1, MA
McCurnin 10th ed. pg 75

80
Q

How old does an individual need to be in order to provide consent?

A

Consent must be given by a legal adult, 18 years or older
#1, MA
McCurnin 10th ed. pg 76

81
Q

What does MOAR stand for?

A

Medication administration/order record (aka ward treatment sheet)
#15
HP
McCurnin 9th ed. Pg 93

82
Q

What are two secondary purposes of medical records?

A

The medical record supports businesses and services rendered to the pet by listing them and medical records can support research.
#15
HP
McCurnin 9th ed, pg. 78

83
Q

What are some important tenets of medical record keeping?

A
  1. They should be maintained in such a manner that another veterinary professional could easily understand the case and proceed with proper care.
  2. Should include all clinical information to support the diagnosis and treatment given.
  3. Entries indicating future care should always be documented, whether or not the client followed through
    #12 JL
    McCurnin 10th ed, pg. 73
84
Q

Examples of different veterinary practice management software

A

AVImark, DVMax, ezyVet, NaVetor, VetBlue Clinic
#12 JL
McCurnin 10th edition, pg.73

85
Q

What does SOAP stand for?

A

Subjective, Objective, Assessment, Plan
#12 JL
McCurnin 10th edition, pg. 72

86
Q

Preventative Medicine Program

A

Immunizations, parasite control, dental care program, ear care program, spay/neutering, and exercise program
#12 JL
McCurnin 10th ed, pg.82

87
Q

Examples of recent history information

A
  • Presenting complaint and circumstances
  • Date when last normal
  • Location and character of problem
  • Current medications
  • Treatment efforts
  • Comments and concerns of owner
  • Current diet
    -Recent changes in environment, household schedule, or pets/humans in household
  • FAS score
  • Information from previous or referring veterinarian
    #12 JL
    McCurnin 10th ed, pg.82
88
Q

What is a laboratory diagnostic flow sheet?

A

A laboratory diagnostic flow sheet is a compilation of laboratory data for an individual patient
#15
HP
McCurnin 9th ed. pg 87

89
Q

In the medical records, what should be included in patient information?

A

The name of the animal, signalment, color and markings, tattoos, identification numbers, and microchip numbers.
#15
HP
McCurnin 9th ed. pg. 83

90
Q

When can information within medical records be released?

A

Medical record information can be released at the consent of an owner of the patient or when needed by the law.
#15
HP
McCurnin 9th ed. pg. 79

91
Q

The difference between a tech assessment and a veterinarian’s assessment?

A

A tech’s assessment includes their evaluation of the patient’s physical, social, psychological, and environmental conditions. A vet’s assessment would contain medical or surgical differential diagnoses.
Student #7, HHS
McCurnin 10th edition, pg:87

92
Q

Alphabetic vs numeric filing?

A

In alphabetic filing client files are placed in alphabetic order, the most common cause of misfiling is misspelled names.
In numeric filing each client is assigned a number and files are placed in ascending or descending order, misfiling is more easily recognized with this method of paper filing.
Student #7, HHS
McCurnin 10th edition, pg:100

93
Q

File out placeholders can be used to indicate what?

A

These placeholders can indicate that the file is in use and can even contain notes on the file’s location.
Student #7, HHS
McCurnin 10th edition, pg:99

94
Q

AAHA requirement for the storage of paper patient records.

A

AAHA requires records to be stored in standard letter-size folders
Student #7, HHS
McCurnin 10th edition, pg:97

95
Q

What are some reasons a client may request a copy of the patient’s record to be released to a third party?

A

They are moving to a new practice, they need to prove their vaccination history, for insurance claims, or to release to scientists to include in studies
Student #7, HHS
McCurnin 10th edition, pg:79

96
Q

What are text-to-speech options for medical record entering?

A

Dragon. Windows speech recognition.
Student #17 TSR
McCurnin 10th edition pg. 94

97
Q

What is another way we can prevent loss of electronic medical records?

A

Backup servers incorporated into the network.
Student #17 TSR
McCurnin 10th edition pg. 94

98
Q

What order should the technician assessments go?

A

Most urgent to least urgent.
Student #17 TSR
McCurnin 10th edition pg. 87

99
Q

How do we correct a written mistake in the medical record?

A

Draw a line through it an initial/date.
Student #17 TSR
McCurnin 10th edition pg. 73

100
Q

What abbreviations can be used in the medical record?

A

Standardized and approved ones. Refer to AHHA.
Student #7 TSR
McCurnin 10th edition pg. 73

VET 2050 SP 23 (9 decks)

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