History Taking Flashcards
What is the legal importance of medical records?
-It’s a legal document so it can be used in a court of law
-If you didn’t write it, it didn’t happen
-NY maintains records for 3 years after last visit
What is the medical importance of a medical record?
-Prior history
-Clarity
How should entries be made in a record?
-Black ink
-Errors crossed out with one line and initialed
-Date every entry
-Initial every entry
What should the patient record include?
-Basic info on the client
-Basic info on the patient
What is basic client info?
-Name
-Spouse name
-Address
-Place of employment
-Phone number
-Email
What is basic patient info?
-Name
-Record number
-Signalment
-Species
-Breed
-DOB
-Sex
-Reproduction status
What is signalment?
A detailed description for purposes of identification
Shorthand for male
M
Shorthand for female
F
Shorthand for neutered male
MN
Shorthand for spayed female
FS
Shorthand for vaccination
Vx
Shorthand for history
Hx
Shorthand for diagnostic testing
Dx
Shorthand for physical exam
PE
Shorthand for treatment
Tx
Shorthand for surgical
Sx
Shorthand for medications
Rx
What does SOAP stand for?
Subjective, Objective, Assessment, Plan
What falls under the subjective category?
-Qualitative assessment: how the patient appears
-BAR (bright, alert, responsive)
-QAR (quiet, alert, responsive)
What falls under the objective category?
-Quantitative assessment: measurable data
-TPR: temperature, pulse, respiratory rate
What falls under the assessment category?
-Concerns and differential diagnosis
-Completed by vet
What falls under the plan category?
-Diagnostic plan
-Treatment plan
-Done by a vet
What is a symptom?
Changes in bodily functions that are reported by a patient
What is a sign?
Clinical findings noted by a medical professional (animals only have signs)
What needs to be included in the history?
-Signalment
-Weight
-Diet
-Water consumption
-Urination
-Past medical history
-Medications currently taking
-Allergies
-Environmental history
-Exercise
-Work
-Behavior
What needs to be included in past medical history?
-Vaccination history
-Past medical problems
-Permission to obtain records from previous vet(s)
What needs to be in the history of present problems?
-Cheif complaint/ presenting problem
-Onset
-Frequency
-Trigger
-Duration
-Progression
-Relief
