Medical Records Flashcards
In nys records must be maintained for ____ years after the last visit
3
In NYS controlled substance logs must be maintained for _____ years
5
Can records and controlled sub logs be used in a court of law?
Yes, they are legal documents
If something is not written down, do you have record that it occurred?
No
Medical importance of good medical records
Prior history helpful when a problem recurs or related one develops
Clarity for clinic staff and clients to ensure good care
Who owns the medical records
The practice NOT the owner
The practice must provide a copy of medical records upon the owners
Written and signed request
Before releasing med records to another party, the practice must
Obtain the owners signed request
When the client changes vets, it is advisable to mail a copy of the record with
A cover letter (clients written and signed permission)
If animal has a reportable disease
Regulatory agencies must be notified with or without owners permission
Where to notify of reportable diseases
USDA
CDC
DOH or public health
Do you need permission from client to release records if they have been subpoenaed (summoner) in court
No
If an animal bites a human
Rabies vaccination history may be provided upon request to
Public health d
The bite victims physician
Animal control
If an animal bites another animal
Rabies vaccination history may be provided (upon request) to
The other animals vet
Animal control
Exceptions to record release rules
Reportable diseases
Subpoenaed in court
Animal bites human or other animal
Every entry in records should be
Written in black ink or typed
Date and time of every entry
Initial and credentials for every entry
Errors in a record should be
Readable, crossed out w single line, initialed
Patient record should include what ab the client
Name & spouses name Address Employment # at home work cell and fax Email
Patient record should include what info ab patient
Name Case or record # Signalment Vx, Hx, PE, WNL or N, Dx, Tx, Sx, Rx, MAOR Progress notes
Signalment
Detailed description for purposes of identification
Signalment includes
Species, breed, color and markings, microchip # or tat #
Dob (write est. if estimated)
Sex and reproductive status
Sex and reproductive status M F M(N) or M/N F(S) or F/S
Male
Female
Neutered male
Spayed female
Are female reproductive status part of signalment
Why or why not
No because they change
Stage of estrus, pregnancy, lactation
Every page of record should
Identify patient it belongs to (labels)
Vx Hx Dx Tx Sx Rx
Vaccination history Diagnostic Treatment Surgical Medications
MAOR
PE
Medication administration order record- table to record treatments, feedings, waste elimination, etc at specific times when hospitalized
Physical exam
Informed consent
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
Medical record format: conventional (source oriented) (SOVMR)
Info is entered as it occurs
Medical record format: problem oriented (POVMR)
List of problems identified
POVMR master problems list
Diagnosed problems over animals lifetime
Working POVMR problems list
Current problems, progress notes are completed for each problem daily during hospitalization
Progress notes format for POVMR
SOAP Subjective Objective Assessment Plan
SOAP: Subjective
Qualitative assessment, how patient appears
Opinionated
SOAP Objective
Quantitative assessment, measurable data
TPR, temp pulse RR
SOAP
Assessment
Concerns of differential diagnoses (DDx)
Usually completed by veterinarian
VT could narrow down a list of possible issues
SOAP Plan
Diagnostic plan and treatment plan
Usually completed by veterinarian
BAR and QAR
Bright, alert, responsive
Quiet, alert, responsive (could be shy or in pain)
Signs and symptoms are abbreviated as
Sx (depends on context)
Symptoms(Sx)
Changes in bodily functions or sensation that are reported by patient
Signs (Sx)
Clinical findings noted by medical professional
Human patients have (signs or symptoms) Animals have (signs or symptoms)
Both
Signs only, bc they are unable to verbally report symptoms
Logs
List of patients that undergo certain categories of procedures
Purposes of logs
Quickly determine when certain procedures were done, how many, to whom
Quality control
Ensure charges captured
Comply w legal requirements for backup
Logs should list
Date and time Name of client and patient Procedure performed Initials of who performed Complications
Types of logs include
Surgery Anesthesia Controlled sub Radiology Ultrasound Lab Euthanasia Necropsy Etc
What type of log is required by law
Controlled substance logs
Info listed in logs should also be in _______
Each animals record
2 kinds of medical record formats
Conventional, SOVMR source oriented
POVMR problem oriented
