Medical Records

Question 1

In nys records must be maintained for ____ years after the last visit

Answer 1

3

Question 2

In NYS controlled substance logs must be maintained for _____ years

Answer 2

5

Question 3

Can records and controlled sub logs be used in a court of law?

Answer 3

Yes, they are legal documents

Question 4

If something is not written down, do you have record that it occurred?

Answer 4

No

Question 5

Medical importance of good medical records

Answer 5

Prior history helpful when a problem recurs or related one develops
Clarity for clinic staff and clients to ensure good care

Question 6

Who owns the medical records

Answer 6

The practice NOT the owner

Question 7

The practice must provide a copy of medical records upon the owners

Answer 7

Written and signed request

Question 8

Before releasing med records to another party, the practice must

Answer 8

Obtain the owners signed request

Question 9

When the client changes vets, it is advisable to mail a copy of the record with

Answer 9

A cover letter (clients written and signed permission)

Question 10

If animal has a reportable disease

Answer 10

Regulatory agencies must be notified with or without owners permission

Question 11

Where to notify of reportable diseases

Answer 11

USDA
CDC
DOH or public health

Question 12

Do you need permission from client to release records if they have been subpoenaed (summoner) in court

Answer 12

No

Question 13

If an animal bites a human

Answer 13

Rabies vaccination history may be provided upon request to
Public health d
The bite victims physician
Animal control

Question 14

If an animal bites another animal

Answer 14

Rabies vaccination history may be provided (upon request) to
The other animals vet
Animal control

Question 15

Exceptions to record release rules

Answer 15

Reportable diseases
Subpoenaed in court
Animal bites human or other animal

Question 16

Every entry in records should be

Answer 16

Written in black ink or typed
Date and time of every entry
Initial and credentials for every entry

Question 17

Errors in a record should be

Answer 17

Readable, crossed out w single line, initialed

Question 18

Patient record should include what ab the client

Answer 18

Name & spouses name 
Address 
Employment 
# at home work cell and fax 
Email

Question 19

Patient record should include what info ab patient

Answer 19

Name 
Case or record # 
Signalment 
Vx, Hx, PE, WNL or N, Dx, Tx, Sx, Rx, MAOR
Progress notes

Question 20

Signalment

Answer 20

Detailed description for purposes of identification

Question 21

Signalment includes

Answer 21

Species, breed, color and markings, microchip # or tat #
Dob (write est. if estimated)
Sex and reproductive status

Question 22

Sex and reproductive status 
M 
F 
M(N) or M/N 
F(S) or F/S

Answer 22

Male
Female
Neutered male
Spayed female

Question 23

Are female reproductive status part of signalment

Why or why not

Answer 23

No because they change

Stage of estrus, pregnancy, lactation

Question 24

Every page of record should

Answer 24

Identify patient it belongs to (labels)

Question 25

Vx Hx 
Dx 
Tx 
Sx 
Rx

Answer 25

Vaccination history 
Diagnostic 
Treatment 
Surgical 
Medications

Question 26

MAOR

PE

Answer 26

Medication administration order record- table to record treatments, feedings, waste elimination, etc at specific times when hospitalized
Physical exam

Question 27

Informed consent

Answer 27

Forms signed by clients saying that they have been sufficiently educated ab procedures (risks, prognosis, cost)
And
Client consents to the procedures and agrees to the cost

Question 28

Medical record format: conventional (source oriented) (SOVMR)

Answer 28

Info is entered as it occurs

Question 29

Medical record format: problem oriented (POVMR)

Answer 29

List of problems identified

Question 30

POVMR master problems list

Answer 30

Diagnosed problems over animals lifetime

Question 31

Working POVMR problems list

Answer 31

Current problems, progress notes are completed for each problem daily during hospitalization

Question 32

Progress notes format for POVMR

Answer 32

SOAP 
Subjective 
Objective 
Assessment 
Plan

Question 33

SOAP: Subjective

Answer 33

Qualitative assessment, how patient appears

Opinionated

Question 34

SOAP Objective

Answer 34

Quantitative assessment, measurable data

TPR, temp pulse RR

Question 35

SOAP

Assessment

Answer 35

Concerns of differential diagnoses (DDx)
Usually completed by veterinarian
VT could narrow down a list of possible issues

Question 36

SOAP Plan

Answer 36

Diagnostic plan and treatment plan

Usually completed by veterinarian

Question 37

BAR and QAR

Answer 37

Bright, alert, responsive

Quiet, alert, responsive (could be shy or in pain)

Question 38

Signs and symptoms are abbreviated as

Answer 38

Sx (depends on context)

Question 39

Symptoms(Sx)

Answer 39

Changes in bodily functions or sensation that are reported by patient

Question 40

Signs (Sx)

Answer 40

Clinical findings noted by medical professional

Question 41

Human patients have (signs or symptoms) 
Animals have (signs or symptoms)

Answer 41

Both

Signs only, bc they are unable to verbally report symptoms

Question 42

Logs

Answer 42

List of patients that undergo certain categories of procedures

Question 43

Purposes of logs

Answer 43

Quickly determine when certain procedures were done, how many, to whom
Quality control
Ensure charges captured
Comply w legal requirements for backup

Question 44

Logs should list

Answer 44

Date and time 
Name of client and patient 
Procedure performed 
Initials of who performed 
Complications

Question 45

Types of logs include

Answer 45

Surgery 
Anesthesia 
Controlled sub 
Radiology 
Ultrasound 
Lab 
Euthanasia 
Necropsy 
Etc

Question 46

What type of log is required by law

Answer 46

Controlled substance logs

Question 47

Info listed in logs should also be in _______

Answer 47

Each animals record

Question 48

2 kinds of medical record formats

Answer 48

Conventional, SOVMR source oriented

POVMR problem oriented