Medical Records Flashcards
Medical records are?
One of the most important and complicated tasks for the hospital staff. Veterinary medical records include a wide range of forms and logs that document the treatment and care of patients.
The primary purpose of medical records is?
To support the patients medical care by documenting:
- Diagnostic procedures
- Diagnoses
- Prognoses
- Treatment
Medical records support excellent medical care by?
- Aiding in identification of client and patient.
- It helps in generating an effective diagnostic and treatment plan.
- Physical exam findings.
- Diagnostic procedures and tests to be performed.
- Records the veterinarians differential diagnoses ideas.
- Documents patients responses to treatment.
- Supports continuity of care.
- It documents communication with the client.
- Assists in the generation of reminder postcards that help owners stay current with their preventative medical care.
- Aids interactions with the clients and their pets.
The secondary purposes of medical records includes?
- Evaluations of medical information for:
- Business
- Legal
- Research
- The medical record lists all the services rendered to the pet.
- It verifies services billed to the owner.
- It serves as legal evidence of the services received by the owner.
Medical records are also used to assess?
- Staffing.
- Formulate income analysis.
- Help budget.
- Helps maintains inventory.
- Generates marketing strategy.
- Plays an important role in hospital accreditation.
- Helps assess compliance with standards of care.
Medical records are used as?
- A legal document in a court of law during litigation.
- It serves as evidence of procedures and treatments performed by providing specific dates and times.
- It is critical in defending against malpractice suits.
- It must be complete and accurate.
- In court, if it is not written and initialed, it has not been done.
- Insurance will require to decide whether to pay a claim.
- They are an important element in preparing case studies, research and presentations.
- All patient information (name, etc) must be removed to maintain patient confidentiality
There are 2 major types of medical records…..
- Letter Sized Folders
- Pocket Card Files
Ambulatory large animal practices will?
- Use carbon forms and/or computers.
- There has been a large shift to laptop computers.
- Records are not always kept on individual animals but on the entire herd.
Veterinary Medical records are not?
Subject to the same federal and state regulations as human medical records.
The most widely used format is?
The problem-oriented veterinary medical record (POVMR).
POVMR is used in?
- Teaching hospitals.
- AAHA-accredited hospitals.
- Specialty/referral hospitals.
- Most private hospitals.
POVMR commonly includes?
- Client patient information.
- History.
- Physical exam.
- Master problem list and working problem list.
- Progress notes, assessment, and plan.
- Pertinent forms: surgery, anesthesia, radiography, laboratory reports.
- Case summary.
- Fee information.
Paperless applies to?
A practice that manages all of its information on one computer system.
Currently, most computerized practices are considered to be?
Paper light (lite) since they still generate tons of information which is not stored in the computer.
Examples of this are:
- Radiographs.
- Consent forms.
- Faxes.
- New client/patient registration forms.
- Referral letters.
- All the practice logs.
- Medical records from other practices.
With the advent of better more affordable?
Technology:
- like scanners
- CD-ROM technology
- signature capture
We can become more paperless.
Electronic media storage is?
Safer than printed media storage.
- It must be backed up and stored off site.
- CDs can store thousands of documents.
- On line external site back can store unlimited amounts of information.
Legalities of computerized record storage….
- To date, no paperless case has gone to court, so it has not been tested.
- Medical records must be protected from alteration after the fact.
- Proof of electronic medical record security can be provided by having the backups kept at an off site data storage facility.
- A comparison can then be made by the court to ensure both copies match which would ensure that the information contained in the medical record has not been altered and corrupted.
- In any system, all entries must be initialed by the person making them.
All of the new technology costs the practice?
Large sums of money initially, but in the long run it provides a great return on investment.
Current technology includes:
- Digital cameras
- Flatbed scanners
- Digital radiology
- Computerized digital otoscope/endoscope
- Digital ultrasound
SOAP stand for?
Subjective
Objective
Assessment
Plan
The S (subjective in SOAP) is?
The way the patient appears to the casual observer.
The O (objective in SOAP) is?
Physiological data.
- TPR
- Vomiting/defecation/urination
- Lab work results*Usually done by the technician
The A (assessment in SOAP) is?
The veterinarian would record the status of the patient.
Ie. Post surgical no recovery issues.
Ie. PU/PD
The P (plan in SOAP) is?
The course of action that will be taken that day as per the veterinarian.
What are some of the forms we looked at?
- Top sheet client/patient information.
- Second sheets.
- Sticker sheets.
- Pet report card.
- Dermatology questionnaire.
- In hospital boarding medication sheet.
- Status of admitted patients.
- Post operative checklist.
- Pain management.
- Informed consent.
- Discharge instructions.
- Estimate.
- Euthanasia.
What are some examples of medical logs?
- Lab
- Anesthesia
- Surgery
- Radiology
- Adverse reactions
- Sentinel events
- OSHA training
- Controlled substances
Signalment is?
The first information you receive from the owner. It includes (of the patient):
- Age
- Breed
- Sex
- Species
It is usually collected along with the client information by the receptionist.
Medical Record Maintenance
- Active patient medical records covering a 3 year period are maintained in the primary medical records collection.
- Records that are inactive 4 years or more are moved to storage that is easily accessible.
- Inactive records that are 8 years old or older can be taken from storage and shredded.
- Deceased patient records must be treated the same way.
Medical Record Ownership
-Medical records along with radiographs, etc are the property of the veterinary practice.
- Owners may obtain a copy of their records upon request. (it can’t be held if there is money due).
- Remember there are regulations regarding release of medical records.
-A fee can be charged for the copies.
