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Office Management > Veterinary Medical Records (Chapter 5) > Flashcards

Veterinary Medical Records (Chapter 5) Flashcards

1
Q

What is a Medical Record?

A

a permanent written account of the professional interaction and services rendered in a valid patient-client relationship

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2
Q

What are the 2 categories of the functions of the medical records?

A

primary purposes

secondary purposes

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3
Q

What are the Primary Purposes of Medical Records?

A

supports excellent medical care

documents communication

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4
Q

Supports Excellent Medical Care

A

assists in correct ID of patient and owner
aids in generation of effective diagnostic and treatment plan
supports continuity of care

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5
Q

Documents Communication

A 
take home instructions
generation of reminder cards
personal information
-financial limitations
-behavioral idiosyncrasies
-future plans
-names of family members
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6
Q

What are the Secondary Purposes of Medical Records?

A

supports business and legal activities

supports research

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7
Q

Supports Business and Legal Activities

A

verifies billing
legal evidence of services received by owner
assesses workloads of staff members
income analysis and budgetary planning
marketing strategies
assesses compliance with standards of care for accreditations

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8
Q

Supports Research

A

preparation of case studies
retrospective studies to help predict clinical outcomes
teaching veterinary students

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9
Q

What are the Cons of Paper Records?

A 
not 100% consistent
legibility is a concern
damaged by fire/water
misplaced
torn, crumpled, yellows with age
large storage space required
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10
Q

What are the Pros of Paper Records?

A

generally easy to use

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11
Q

What are the Cons of Computer Records?

A 
damaged/lost files
power outages
data storage space
initial start up cost
training usually required
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12
Q

What are the Pros of Computer Records?

A

consistent format
easier to access
quickly copied
easily transported

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13
Q

What are the types of Patient Records?

A

letter-size folders
card files
carbonized sheets
computerized

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14
Q

Letter-Size Folders

A

8.5 X 11 inch paper
fastened into a file folder
stored vertically on shelves

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15
Q

What type of Patient Record is the AAHA standard?

A

letter-size folders

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16
Q

Card Files

A

5 X 8 or 10 X 16 inch index cards
filed in pocket folders or card boxes
usually filed in drawers alphabetically

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17
Q

Carbonized Sheets

A

more cost effective and practical for ambulatory and large animal practices
-whole herd records common
one copy of invoice page is given to owner and the other is taken to home practice to be input into computer
laptops are quickly replacing carbonized sheets for record-keeping

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18
Q

What are ways to Organize and File Patient Records?

A

alphabetic by owner last name
numeric by client number
color code system

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19
Q

What is a common mistake made when filiing a patient record Alphabetically?

A

misfilling

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20
Q

T or F: Patient files should be reviewed annually

A

True

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21
Q

T or F: AVMA guidelines require that active records covering a 6 year period be readily accessible

A

False

3 year period

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22
Q

T or F: Texas law states that records covering a 5 year period be readily available

A

True

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23
Q

T or F: Records inactive for 4 years can go into storage

A

True

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24
Q

T or F: Inactive records can be shredded when they reach 10 years of age

A

False

when they reach 8 years of age

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25
Q

What are the types of Formats of Patient Records?

A

source oriented medical records (SOMR)
problem oriented medical records (POMR)
combination (problem/source oriented)

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26
Q

When are SOMRs typically used?

A

in records that have limited space, such as in the card or pocket type records

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27
Q

How are entries made in SOMRs?

A

free form

28
Q

What are the Pros of SOMRs?

A

easy to learn

takes little time to complete

29
Q

What are the Cons of SOMRs?

A

lack detailed documentation
“if its not written down, it didn’t happen”
forget to write things down
hard to find things
have to go through “stories” to get information
AAHA doesn’t like this format

30
Q

Where are POMRs used?

A

teaching hospitals
AAHA-accredited hospitals
private practices
speciality and emergency centers

31
Q

What does the POMR format help to provide?

A

provide a whole view of the patient and supports a logical and organized approach to clinical medicine

32
Q

What format must be used in AAHA accredited hospitals?

A

POMR

33
Q

What do POMRs commonly include?

A 
client and patient information
history
physical exams
master problem list and working problem list
progress notes, assessment and plan
pertinent forms: surgery, anesthesia, radiography, special imaging, and lab reports
case summary
fee information
34
Q

What does a comprehensive history include?

A

both previous and recent history information

35
Q

When is a comprehensive history taken?

A

during each new patient visit and during visits from those patients that have not been seen in years

36
Q

What does Previous History Information include?

A

origin: animal’s birthplace and date
preventive medicine program: immunizations, parasite control, dental care program, ear care program
behavior: usual disposition and temperment, unusual behavioral events
environment: kept indoors or outdoors, presence of other pets in home, level of exposure to non-family owned pets, travel history
known allergies and reactions: atopy, food, contact with substances, medications, blood transfusions
reproduction: neutered, estrus cycles, when bred, number of litters
previous conditions, trauma or surgical operations

37
Q

What does Recent History Information include?

A 
presenting complaint and circumstances 
last normal
frequency of episodes
current meds
treatment efforts
comments and concerns of owner
current diet
information from previous or referring vet
38
Q

T or F: In the POMR, the signalment, history, physical exam, and diagnostic tests are collectively known as the database

A

True

39
Q

T or F: In ER and critical care units, the database is considered to include 5 or 6 important pieces of information that are key in treating the critical patient

A

True

40
Q

What information is included in the database in ER and critical care units?

A 
PCV
total solids
potassium
BUN
dextrose
urinalysis
41
Q

What is the Master Problem List?

A

includes the major medical disorders experienced by a patient during it’s lifetime

42
Q

What is the Working Problem List?

A

assists the technician in working through problems that are relevant to the current hospital stay

43
Q

What does SOAP stand for?

A

subjective
objective
assessment
plan

44
Q

What are the 2 types of SOAPs?

A

traditional (used in clinic)

academic (used in schools)

45
Q

S (traditional)

A

way the patient appears from the point of view of the owner

46
Q

O (traditional)

A

includes physiologic data such as temp, pulse, respiration

also would note vomitus, urination and defecation and describe color and consistency if applicable

47
Q

A (traditional)

A

record the status of the patient
usually Dr.’s portion
where diagnosis and differential diagnosis is

48
Q

P (traditional)

A

refers to the course of action that will be taken that day

the medication to be given, procedures, and treatment plans are recorded here

49
Q

S (academic)

A

truly subjective
ex: BAR, QAR, weight, behavior, appetite
if someone can argue it, it’s subjective

50
Q

What is a Differential Diagnosis?

A

list of things that might be wrong based on owner and physical exam findings

51
Q

O (academic)

A 
TPR
weight (lbs)
BCS
lab results
current meds
52
Q

A (academic)

A 
largest part of the SOAP
where dx and Ddx belong
anything abnormal noted in S and O must be assessed here
assess behavior
every problem gets a number
53
Q

P (academic)

A

look at assessment
every problem needs a plan
what is your plan to solve the problems?

54
Q

What are the 2 purposes of logs?

A

provide additional documentation for legal support

provide data for quick analysis and retrospective studies

55
Q

What are some commonly used logs?

A 
radiology log
surgery log
anesthesia log
necropsy log
controlled substances log
56
Q

What information is included in a Radiology log?

A 
patients name and ID number
client's name
date
study type
measurement of body thickness
technique used: milliamperes (mA), time, kilovolts peak (kVp)
radiographic findings or diagnosis
57
Q

What information is included in a Surgery log?

A 
date
animal and owner's name
case number
patient's weight
name of surgeon
surgical procedure
duration of surgery
complications
58
Q

What information is included in an Anesthesia log?

A 
patient's and owner's name
patient's weight
relative risk category or result of physical examination
anesthetic protocol, including type and dosage of each anesthetic agent
anesthesia start and end time
number of intubation attempts
surgical procedure and name of surgeon
anesthetist's name
complications
59
Q

T or F: An inventory of all controlled substances must be made every 2 years

A

True

60
Q

What information is included in a Controlled Substance log?

A 
date
owner's and patient's name
starting volume
ending volume
amount used
the initials of the person who used the drug
61
Q

How long must all Controlled Substances inventory records be kept?

A

2 years

62
Q

T or F: The client is by law the owner of their animals medical record

A

False

they are owned by the hospital or the hospital owner

63
Q

What are the guidelines for generating clear, complete and accurate records?

A

entries should either be typed or written in black ink
in court, handwriting alone isn’t an adequate way to identify the author of a notation. entries should be dated and initialed to identify the person making the entry
errors should not be scratched out, erased, or blotted out.
only approved standard abbreviation should be used

64
Q

How should an error in a patient’s chart be corrected?

A

a single line should be drawn through the mistake and initialed
the correct information should then be written in the margin and initialed and dated next to the correction

65
Q

T or F: The medical record is considered legal evidence of services and procedures performed by the veterinary health care team

A

True

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