wk 12

Question 1

what best describes the primary purpose of a patient medical record?

Answer 1

Provide a historical account of a patient’s healthcare

Question 2

Because medical records may be used as evidence in a malpractice suit, what is most appropriate to include in them?

Answer 2

Copy of any written communication between the practice and the client

Question 3

An illegible and incomplete medical record can be viewed by a court of law as
what

Answer 3

Admission of professional incompetence

Question 4

A veterinary technician makes an error on a medical record. What is the most appropriate way for the technician to correct it?

Answer 4

Strike out the error with one line, make the correction, and place his/her
initials next to it

Question 5

A good medical record filing system organizes the files by what system?

Answer 5

Alphabetically by clients’ last names or by client numbers

Question 6

what is the most appropriate way for the clinic staff to organize the medical records of a client with numerous pets?

Answer 6

All in one client file but separated by tabs denoting each pet’s name

Question 7

what is the ideal way to call team members’ attention to a special note in a medical record?

Answer 7

Place a color-coded sticker on the record.

Question 8

A client who is contemplating buying a cat from a neighbor, who also happens to
be a client of the practice, calls to ask if the practice will provide a copy of the
medical records for the cat. What is the most appropriate response?

Answer 8

“The client from whom you will buy the cat will have to come in to sign a release form.”

Question 9

A client calls a practice to request the medical records for a cat that has recently been diagnosed with asthma and that will be taken to a veterinary specialist. What is the most appropriate response?

Answer 9

“We will be happy to send copies of the records to the specialist.”

Question 10

Every patient of a practice must have a medical record that is legible, well
organized, and complete. What is an additional criterion?

Answer 10

record is easily retrievable

Question 11

A 14-year-old female mixed-breed dog is brought to the hospital by a passing
motorist who saw the dog by the side of the road. The veterinary assistant
recognizes the dog as a patient who is brought in for wellness examinations
approximately twice per year. The assistant checks the records and dials the owner’s home phone number, but the number has been disconnected. The
assistant recalls that the client works for a local supermarket, calls the market,
and reaches the client. When asked about the disconnected phone number, the client says, “Oh, I haven’t lived in that house for 2 years.” Besides updating the
record with the client’s new phone number, what is the most appropriate course of action?

Answer 11

Reiterate to the staff that client contact information should be verified at
every client visit

Question 12

What is the name of a summary sheet that includes patient name, gender,
species, breed, age, diet, allergies, vaccinations, and current medications?

Answer 12

Master problem sheet

Question 13

The veterinarian is monitoring a patient for Cushing’s disease. What document
would be particularly helpful to review?

Answer 13

Diagnostic flow sheet

Question 14

what is the most commonly used format for medical records?

Answer 14

Problem-oriented medical records

Question 15

Following the SOAP format, what is most likely to be considered appropriate for inclusion in the “S” section of the POMR?

Answer 15

The owner reports that the dog has become lethargic and is not eating
well

Question 16

Following the SOAP format, what is most likely to be considered appropriate for inclusion in the “A” section of the POMR?

Answer 16

After reviewing laboratory results and clinical findings, a veterinarian
determines that a dog has intestinal lymphangiectasia

Question 17

Following the SOAP format, what is most likely to be considered appropriate for inclusion in the “O” section of the POMR?

Answer 17

Palpation of a lump over the right mandible of a dog elicits pain

Question 18

Following the SOAP format, what is most likely to be considered appropriate for inclusion in the “P” section of the POMR?

Answer 18

A dog’s wound will undergo surgical debridement

Question 19

what best describes an inactive medical record?

Answer 19

has not been updated in the past year

Question 20

Most states require that inactive medical records be held for at least a 3-year
period. After 3 years, what is the most appropriate way to discard an inactive record?

Answer 20

Shred them

Question 21

A radiograph of a patient should include the veterinary hospital’s name and
address, client’s and patient’s names, and the date the radiograph was taken.
What additional information is most appropriate to include?

Answer 21

Left/right indicator

Question 22

A veterinarian has written the following pharmacotherapy on a medical record: 5
mg diazepam PO. What does this most likely mean in layman’s terms?

Answer 22

5 milligrams of the drug diazepam given orally (by mouth)

Question 23

A veterinarian has written the following pharmacotherapy on a medical record:
sodium bicarbonate (2 mEq, IV). What does this most likely mean in layman’s terms?

Answer 23

2 milliequivalent of sodium bicarbonate given intravenously