Medical Records and History Taking Flashcards
What information does the signalment include?
DOB, sex, reproductive status, species
Where does the data we gather come from?
PE, tests, history
What are some things you can do to develop rapport with a client?
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
What type of questions allow clients to tell their story?
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
What is the first question to ask any client?
What brings you in today
What can we do for you today
What can I help you with today
Why do we keep medical records?
Enables and supports effective treatment and care by documenting
Evaluation of the medical information for business, legal, and research purposes
What 5 things are standardly included in medical records?
Client and patient information Database Master Problem List Working problem list Progress notes
What is included in the database?
Signalment, history, physical exam, diagnostic test results
What is included in a master problem list?
chronological list of major medical disorders
What is included in the working problem list?
list of current problems
What is included in progress notes?
date and time, presenting complaint, PE findings, working problem list
What does SOAP stand for?
Subjective, Objective, Assessment, Plan
What information is included in Subjective?
Presenting complaint/reason for visit
History
Subjective assessment of patient
What information is included in Objective?
Physical exam findings
Procedures
Diagnostic test results
What information is included in Assessment?
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
What information is included in Plan?
What are the recommendations for patient care
Does the client commit to or decline any or all
Prescriptions
Follow up care guidelines
Who owns a medical record?
owner of clinic
What are some of the basic rules of medical records?
Do not skip lines Record in black only Every page should include animal and owners name and species Date and time clearly noted Sign
In the court of law if something is not recorded what can be assumed?
That the procedure or intervention never occurred
List some other medical record forms CVTs may encounter.
Consent Forms Fee schedules Anesthesia forms Surgery forms Recovery forms Pain management forms Diagnostic procedure records Records from consultations
