Medical Records and History Taking

Question 0

What information does the signalment include?

Answer 0

DOB, sex, reproductive status, species

Question 1

Where does the data we gather come from?

Answer 1

PE, tests, history

Question 2

What are some things you can do to develop rapport with a client?

Answer 2

Greet the client and the patient using their names
introduce yourself and tell the client why you are with them
listen
position yourself on the same side as the client, and at or below the level of the client
don’t be afraid to interact with the pet while talking to the client

Question 3

What type of questions allow clients to tell their story?

Answer 3

Have questions prepared ahead of time
Have open ended questions
Make sure your questions are non judgmental
Address the presenting complaint
Attempt to get a progression of the problem

Question 4

What is the first question to ask any client?

Answer 4

What brings you in today
What can we do for you today
What can I help you with today

Question 5

Why do we keep medical records?

Answer 5

Enables and supports effective treatment and care by documenting
Evaluation of the medical information for business, legal, and research purposes

Question 6

What 5 things are standardly included in medical records?

Answer 6

Client and patient information
Database
Master Problem List
Working problem list
Progress notes

Question 7

What is included in the database?

Answer 7

Signalment, history, physical exam, diagnostic test results

Question 8

What is included in a master problem list?

Answer 8

chronological list of major medical disorders

Question 9

What is included in the working problem list?

Answer 9

list of current problems

Question 10

What is included in progress notes?

Answer 10

date and time, presenting complaint, PE findings, working problem list

Question 11

What does SOAP stand for?

Answer 11

Subjective, Objective, Assessment, Plan

Question 12

What information is included in Subjective?

Answer 12

Presenting complaint/reason for visit
History
Subjective assessment of patient

Question 13

What information is included in Objective?

Answer 13

Physical exam findings
Procedures
Diagnostic test results

Question 14

What information is included in Assessment?

Answer 14

Create a problem list using the items recorded in O
Is there any procedure that the patient would benefit from
DVM will dictate or record TDx, DDx, Dx and Px

Question 15

What information is included in Plan?

Answer 15

What are the recommendations for patient care
Does the client commit to or decline any or all
Prescriptions
Follow up care guidelines

Question 16

Who owns a medical record?

Answer 16

owner of clinic

Question 17

What are some of the basic rules of medical records?

Answer 17

Do not skip lines
Record in black only
Every page should include animal and owners name and species
Date and time clearly noted
Sign

Question 18

In the court of law if something is not recorded what can be assumed?

Answer 18

That the procedure or intervention never occurred

Question 19

List some other medical record forms CVTs may encounter.

Answer 19

Consent Forms
Fee schedules
Anesthesia forms
Surgery forms
Recovery forms
Pain management forms
Diagnostic procedure records
Records from consultations