Veterinary Medical Records Flashcards
a document made up of all handwritten or typed notes regarding the patient, all laboratory data, all surgical and anesthetic records, all client communications, all specialist referrals, and any other documented information regarding that patient
Medical Record
List 2 secondary purposes of medical records
Business & Legal Based:
1. Support business and legal activities
2. Support research and development
List 2 primary purposes of medical records
Medical Care Based:
1. Support excellent medical care
2. Document communications
assists in the conduction of retrospective studies, in predicting clinical outcomes and is used to teach veterinary medical and veterinary technician students
Veterinary Medical Databases
the basis for all interactions between veterinarians, their clients and their patients
Veterinarian-Client-Patient Relationship (VCPR)
Explain the 5 requirements to claim a VCPR exists
- The vet has assumed responsibility for the animal’s medical care and the client has agreed to follow the vet’s recommendations
- The vet has enough familiarity with the animal to formulate at least a preliminary diagnosis
- The vet is available for follow-up/emergency coverage (or has arranged or such coverage) in the event of an adverse reaction or treatment failure
4.The vet provides oversight of treatment, compliance, and outcome
- Patient records are maintained
ensuring that the client understands all possible aspects of any test or treatment including cost, risks, and expected benefits
Informed Consent
a disease that must be reported to government officials because it is dangerous to the public or to widespread animal health
Reportable Disease
PIMS
Practice Information Management System
Give the 2 primary approached to medical record organization
- Source-Oriented Veterinary Medical Record (SOVMR)
- Problem-Oriented Veterinary Medical Record (POVMR)
an approach to medical record organization that groups information by subject matter and keeps records in reverse chronological order
Source-Oriented Veterinary Medical Record (SOVMR)
an approach to medical record organization that groups records by problem, with each problem being addressed separately, and notes are recorded in SOAP format
Problem-Oriented Veterinary Medical Record (POVMR)
the most recent records being listed first
Reverse Chronological Order
What are the 4 components of POVMR?
- Database
- Master problem list + working problem
- Initial plan + progress notes
- Case summary + discharge instructions
consists of all information available about the patient including signalment, history, results of physical examination, laboratory results, anesthetic recordkeeping sheets, and other additional information
Database
What 5 things make up databases?
- Client information/patient’s signalment
- History - previous/recent
- Physical exam results
- Lab results
- Anesthetic recordkeeping sheets
Give 7 important considerations regarding a patient’s history
- Presenting complaint
- When the problem started
- Description of the problem
- Current medications
- Current diet
- Recent changes in environment or household status
- Other info from client or prior vets
WNL
“within normal limits”
NSF
“no significant findings”
BAR
“bright, alert, and responsive”
a compilation of lab values for all tests performed on an individual outpatient or inpatient animal
Laboratory Diagnostic Flow Sheet
a document that includes the findings, diagnosis, and recommendations for a patient by a specialty veterinarian and is then emailed to the referring practice
Consultation Form
contains a list of all medical disorders experienced by a patient over the course of its lifetime and a final diagnosis for each problem that patient has had addressed in its past
Master Problem List
Another name for a Master Problem List
Diagnosis List
contains a list of current medical problems and is more focused on clinical signs than diagnosis because a diagnosis may not be known at the time the problem is being addressed
Working Problem List
a document that is used to track treatments and diagnostic tests that have been ordered by the veterinarian and may be hung on a patient’s cage for quick access
Medication Administration / Order Record (MAOR)
MAOR
Medication Administration / Order Record
Another name for an MAOR
Ward Treatment Sheet
Explain 6 guidelines for MAORs
- Each order entered should be written exactly as the vet wrote it
- Person giving the treatment writes their initials in the column to indicate time of administration
- Clearly note in patient’s MR if treatment is NOT given
- Put an “X” in the boxes representing the dates when the medication was NOT given at a specific period of time
- Make an entry in a MR if the medication is discontinued
- Leave remaining boxes blank if full recommended duration of medication was not given due to patient discharge
Explain the process for purging medical records
- Keep records of pets that have been see in the last 3 years out for access
- Move records of pets that haven’t been seen between 4-7 years ago to storage
- Shred records of pets that have been seen in 8+ years
How long are electronic medical records able to be changed?
24-48 hours
Once a MR is locked, how are all changes entered?
- Addendum
- New note
What are the 2 purposes of logbooks?
- Provide additional documentation for legal support
- Provide data for quick analysis and retrospective studies
Give a few examples of logbooks used by vet practices
- X-ray
- Anesthesia/Surgery
- Laboratory
- Controlled Substances
- Ultrasonography
- Euthanasia
- Unexpected death
- Drug reaction
- Medical waste
used to maintain records of vaccinations, reproductive histories, and other information regarding an entire herd
Herd Records
