Medical Record

Question 1

Listing your findings on paper or a computer program allows you to organize what and creates what?

Answer 1

• Allows you to organize a rational flow to the patients’ case
• Creates a problem oriented medical record

Question 2

Good records mean what?

Answer 2

Good care for patients
Good communication
Good practice

Question 3

Can you use abbreviations in a medical record?

Answer 3

Yes, but only profesionally accepted ones

Question 4

What is medical communications?

Answer 4

A language and lexicon that facilitates the rapid and precise transmission of information that pertains to patient health and treatment

Question 5

If you do something but do not record it, did it really happen?

Answer 5

NO, if it did not get recorded then it did not happen in a legal sense

Question 6

By the time any legal proceedings reach your clinic, you will have what?

Answer 6

seen other patients
slept hundreds of times
gone on vacation

Question 7

Legible, clear, concise record is your best defense against what?

Answer 7

malpractice

Question 8

What do you need to include in signlament?

Answer 8

Species
Breed
Sex (including if it has been altered)
Age

Question 9

What are the four steps of a problem oriented medical record?

Answer 9

1. database collection
2. problem definition (problem list vs differential diagnosis list)
3. Plan formulation (divide into diagnostic, therapeutic, and client education)
4. Follow up plans (written as SOAPs)

Question 10

The problem list and differential diagnosis will be revised after what?

Answer 10

Diagnostic testing results and repsonse to therapeutic plan

Question 11

What does SOAP stand for?

Answer 11

subjective
objective
assessment
plan

Question 12

What qualifies as subjective?

Answer 12

• initial overall impression
• includes history (historical lab work, previous procedures)
• includes observations that cannot be measured and are subject to interpretation (appetite, attitude)

Question 13

What qualifies as objective?

Answer 13

• current physical exam findings
• lab results
• measurements
• elimination of bowels/bladdder
• oral intake of food/water
• BCS, TPR, weight
  OBJECTIVE IS INFO YOU QUANTIFY, MEASURE, OR COMPARE TO A STANDARD

Question 14

What goes under the assessment section of a SOAP?

Answer 14

• Comments about your interpretation and opinion of the animal’s condition
• identification of problem(s) based on subjective information and objective data, prognosis and condition statements
• includes differential diagnoses

Question 15

The plan section of SOAP can be divided into what three areas?

Answer 15

• diagnostic
• treatment (immediate and future)
• client education

Question 16

True or false: In a SOAP, you list and address every ongoing or unresolved problem every day.

Answer 16

True