medical records

Question 1

medical record

Answer 1

permanent written account of treatment and services between vet care tam and client or patient

Question 2

purpose

Answer 2

accurate historical account
consistent
protects vet against malpractice
used for business or research

Question 3

parts

Answer 3

soap notes
lab results
xrays
estimates
vaccines
written rx
consent forms
discharge
any discussions

Question 4

ownership

Answer 4

hospital or clinic
copy only for client
checked out and return

Question 5

privacy

Answer 5

confidential, only released by owner
pet goes to new owner
numbers and addresses if lost
divorce

Question 6

legibility

Answer 6

hand writing
spelling
blue blk ink
easily producible-law

Question 7

corretions

Answer 7

draw one line
rewrite correct
initial
never erase or white out

Question 8

POVMR

Answer 8

problem oriented vet medical record
reverse chronological order by date
ad: more complete, high communication
disad: time consuming to set up, maintain, takes up space

Question 9

SOR

Answer 9

source oriented record
chronological by date
stored in plastic bag
ad: less time, easier to learn, maintain
disad: lack of detail, unorganized

Question 10

filing ways

Answer 10

alphabetical
color 
numerical
geographical
compination

Question 11

rules for alphabetizing

Answer 11

last name, first name middle
business name stays the same
disregard minor words and symbols
disregard punctuation
hyphenated is one word
apostrophes are one word
roman numbers filed before alpha titles

Question 12

computerized records advantages

Answer 12

less space
information more consistent
always legible
marketing services easier
accessible other location

Question 13

computerized records disadvantages

Answer 13

lost records
can be altered
learning curve
power fails- no access

Question 14

inactive files

Answer 14

not seen patient for a year or more, patient dies(asap) moves new vet

Question 15

vaccines

Answer 15

3 years dont consider inactive until 3 years

Question 16

purge

Answer 16

yearly

Question 17

do not destroy

Answer 17

keep 3-10 years, 7

Question 18

destroying

Answer 18

do not throw away
shred
folders can be reused if still good

Question 19

controlling computer files

Answer 19

back up daily
info saved to server
passed away- inactive asap

Question 20

writing soap notes

Answer 20

techs start P/E

received from client

Question 21

questions to ask

Answer 21

why the visit?
e/d, v/d
any concerns
more questions to follow

Question 22

openended

Answer 22

doesnt allow for yes or no

more descriptive

Question 23

closed ended

Answer 23

requires yes or no

Question 24

leading

Answer 24

doesnt allow client to come up with answer on his/her own

Question 25

SOAP

Answer 25

s-subjective/ opinion
o-objective/fact tpr
a-assessment/ diagnoses
p-plan/ treatment
full sentences
proper abbreviation