Forms and Logs

Question 1

Forms are used to?

Answer 1

• Document all client/patient information, owner’s consent, treatments, laboratory work and procedures done to a patient.
• They are suggested but not mandatory.
• They are used to document client and patient information helping to insure that medical records will be admissible in court and by legally defensible in the event of a legal action.

Question 2

A practice can?

Answer 2

• Design their own forms or certain forms can be purchased for use.
• They can be produced in many types of formats as long as they contain the appropriate information.

Question 3

Forms need to be individualized by?

Answer 3

• Having the pertinent client and patient information embedded in them along with the date.
• All written information in a medical record or on a form should be initialed and dated.

Question 4

A hospital’s medical records should contain an?

Answer 4

Informed consent form which has been thoroughly gone over with the client. It must contain the date, the client’s signature and the signature of the staff member that went over the information with the client.

Question 5

Clients should also be provided with a?

Answer 5

Customized estimate of costs for services to be provided for patients which will be hospitalized for treatment and/or surgery.

Question 6

If a practice is an AAHA practice?

Answer 6

AAHA has specific forms which must be used.

Question 7

Forms, General Info

Answer 7

• Practices who are still fully using paper records will have these in hard copy (written) form.
• Paper-lite practices will have some as hard copy and some as computerized records.
• Paperless practices will have all computerized records using some form of signature capture device for initials and signatures.

Question 8

Examples of Forms

Answer 8

• Medical record top sheet.
• Second treatment record sheet.
• New client/patient registration.
• Consent.
• 3 anesthesia forms; assessment, monitoring and recovery.
• Laboratory
• Medical summary
• In patient flow sheet
• Post operative check list
• Surgery day log
• Pet report card
• Medication dispensing/procedure sheet (used for boarding patients who need medications)
• Modified Pain Scale (monitoring sheet for pain management).

Question 9

Logs are?

Answer 9

Required.

• They may involve AAHA, state or federal regulations.
• The time limit for retaining different types of logs and records varies by regulations.

Question 10

Logs that must be maintained include?

Answer 10

• Adverse reaction/Sentinel event
• Equipment repair and maintenance.
• Laboratory.
• Necropsy.
• Radiology (includes other imaging also, ie. Ultrasound, Cat scan).
• Anesthesia.
• Surgery ( the anesthesia and surgery logs can be combined into 1 log).
• OSHA ( for employee training and 300 and 300A logs).
  
  • covered in OSHA Module
• Controlled Substance (there are multiple logs).
  
  • covered in the Controlled Substance Module