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Vet Office Management > Veterinary Medical Records > Flashcards

Veterinary Medical Records Flashcards

1
Q

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

A

Medical Record

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2
Q

List 2 secondary purposes of medical records

A

Business & Legal Based:
1. Support business and legal activities
2. Support research and development

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2
Q

List 2 primary purposes of medical records

A

Medical Care Based:
1. Support excellent medical care
2. Document communications

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3
Q

assists in the conduction of retrospective studies, in predicting clinical outcomes and is used to teach veterinary medical and veterinary technician students

A

Veterinary Medical Databases

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4
Q

the basis for all interactions between veterinarians, their clients and their patients

A

Veterinarian-Client-Patient Relationship (VCPR)

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5
Q

Explain the 5 requirements to claim a VCPR exists

A
  1. The vet has assumed responsibility for the animal’s medical care and the client has agreed to follow the vet’s recommendations
  2. The vet has enough familiarity with the animal to formulate at least a preliminary diagnosis
  3. 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

  1. Patient records are maintained
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6
Q

ensuring that the client understands all possible aspects of any test or treatment including cost, risks, and expected benefits

A

Informed Consent

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7
Q

a disease that must be reported to government officials because it is dangerous to the public or to widespread animal health

A

Reportable Disease

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8
Q

PIMS

A

Practice Information Management System

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9
Q

Give the 2 primary approached to medical record organization

A
  1. Source-Oriented Veterinary Medical Record (SOVMR)
  2. Problem-Oriented Veterinary Medical Record (POVMR)
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10
Q

an approach to medical record organization that groups information by subject matter and keeps records in reverse chronological order

A

Source-Oriented Veterinary Medical Record (SOVMR)

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11
Q

an approach to medical record organization that groups records by problem, with each problem being addressed separately, and notes are recorded in SOAP format

A

Problem-Oriented Veterinary Medical Record (POVMR)

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12
Q

the most recent records being listed first

A

Reverse Chronological Order

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13
Q

What are the 4 components of POVMR?

A
  1. Database
  2. Master problem list + working problem
  3. Initial plan + progress notes
  4. Case summary + discharge instructions
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14
Q

consists of all information available about the patient including signalment, history, results of physical examination, laboratory results, anesthetic recordkeeping sheets, and other additional information

A

Database

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15
Q

What 5 things make up databases?

A
  1. Client information/patient’s signalment
  2. History - previous/recent
  3. Physical exam results
  4. Lab results
  5. Anesthetic recordkeeping sheets
16
Q

Give 7 important considerations regarding a patient’s history

A
  1. Presenting complaint
  2. When the problem started
  3. Description of the problem
  4. Current medications
  5. Current diet
  6. Recent changes in environment or household status
  7. Other info from client or prior vets
17
Q

WNL

A

“within normal limits”

18
Q

NSF

A

“no significant findings”

19
Q

BAR

A

“bright, alert, and responsive”

20
Q

a compilation of lab values for all tests performed on an individual outpatient or inpatient animal

A

Laboratory Diagnostic Flow Sheet

21
Q

a document that includes the findings, diagnosis, and recommendations for a patient by a specialty veterinarian and is then emailed to the referring practice

A

Consultation Form

22
Q

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

A

Master Problem List

23
Q

Another name for a Master Problem List

A

Diagnosis List

24
Q

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

A

Working Problem List

25
Q

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

A

Medication Administration / Order Record (MAOR)

26
Q

MAOR

A

Medication Administration / Order Record

27
Q

Another name for an MAOR

A

Ward Treatment Sheet

28
Q

Explain 6 guidelines for MAORs

A
  1. Each order entered should be written exactly as the vet wrote it
  2. Person giving the treatment writes their initials in the column to indicate time of administration
  3. Clearly note in patient’s MR if treatment is NOT given
  4. Put an “X” in the boxes representing the dates when the medication was NOT given at a specific period of time
  5. Make an entry in a MR if the medication is discontinued
  6. Leave remaining boxes blank if full recommended duration of medication was not given due to patient discharge
29
Q

Explain the process for purging medical records

A
  1. Keep records of pets that have been see in the last 3 years out for access
  2. Move records of pets that haven’t been seen between 4-7 years ago to storage
  3. Shred records of pets that have been seen in 8+ years
30
Q

How long are electronic medical records able to be changed?

A

24-48 hours

31
Q

Once a MR is locked, how are all changes entered?

A
  1. Addendum
  2. New note
32
Q

What are the 2 purposes of logbooks?

A
  1. Provide additional documentation for legal support
  2. Provide data for quick analysis and retrospective studies
33
Q

Give a few examples of logbooks used by vet practices

A
  1. X-ray
  2. Anesthesia/Surgery
  3. Laboratory
  4. Controlled Substances
  5. Ultrasonography
  6. Euthanasia
  7. Unexpected death
  8. Drug reaction
  9. Medical waste
34
Q

used to maintain records of vaccinations, reproductive histories, and other information regarding an entire herd

A

Herd Records

35
Q
A

Vet Office Management (4 decks)

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