Session 1

Question 1

What is a medical record?

Answer 1

A medical record is a written form of patient information that includes accurate details about patients, organized to allow team members to access information quickly and easily

Question 2

Why are medical records important?

Answer 2

They provide easy access to past observations, treatment protocols, prevent malpractice, and ensure that if it’s not recorded, it didn’t happen.

Question 3

What are the general rules for making entries in a medical record?

Answer 3

• Entries should be legible, signed or initialed.
• Use ink for credibility.
• Record in chronological order with date and time.
• Ensure entries are accurate, objective, and concise.

Question 4

What should you avoid in medical record entries?

Answer 4

• Reflecting future care unless certain it will be performed.
• Making derogatory statements.
• Using correction fluid or altering entries improperly.

Question 5

What are the components included in a medical record?

Answer 5

• Client information forms
• Examination notes
• Progress notes
• Laboratory reports
• Prescriptions
• Consent forms
• Health certificates

Question 6

What does the SOAP acronym stand for in veterinary records?

Answer 6

• S = Subjective
• O = Objective
• A = Assessment
• P = Plan

Question 7

What information is recorded under the “S” in SOAP?

Answer 7

Client observations, concerns, insights, and opinions.

Question 8

What information is recorded under the “O” in SOAP?

Answer 8

Relevant history and physical examination results, which are factual and devoid of opinion.

Question 9

What is the goal of the “A” in SOAP?

Answer 9

To collate information and develop a list of differential diagnoses and prognosis.

Question 10

What does the “P” in SOAP outline?

Answer 10

The plan to address the clinical issue, including recommendations for diagnostics, therapy, and follow-up care.