Medical Records

Question 1

How are records stored?

Answer 1

8.5x11 Manila folders vertically, 5x8 cards in a folder, digitally

Question 2

Technique of records most clinics use.

Answer 2

Computer stored

Question 3

Contents of a medical record.

Answer 3

Intake info, lab results, referrals, estimates, vaccine sheets, consents forms, discharge sheets

Question 4

Each piece of information has its own section of a record.

Answer 4

Problem orientated

Question 5

All information is stored equally and in chronological order in a medical record.

Answer 5

Source orientated

Question 6

What is included in a database?

Answer 6

Signalment, exams, histories

Question 7

Chronologically list of major medical disorders of the pet on the front of the medical record.

Answer 7

Master problem list

Question 8

List of current issue.

Answer 8

Working problem list

Question 9

Most common format of progress notes.

Answer 9

Soap

Question 10

What does soap stand for?

Answer 10

Subjective, objective, assessment, plan

Question 11

Presenting complaint/reason for visit. The history from client.

Answer 11

Subjective

Question 12

No opinion. The facts about the patient. Physical exam findings, procedures, test results, lab results.

Answer 12

Objective

Question 13

Creating a problem list based on physical exam findings. (ie: bad tarter= dental cleaning). Recommendations

Answer 13

Assessment

Question 14

The recommendations to the patient. (Testing, treatment, prescriptions)

Answer 14

Plan

Question 15

What color ink?

Answer 15

Black or blue only

Question 16

How do you correct mistakes?

Answer 16

Single line through the mistake, write “error” and initial

Question 17

Written agreements between the veterinarian and the client outlining risks and responsibilities (cost).

Answer 17

Consent form

Question 18

MAOR

Answer 18

Medical administration/order record

Question 19

MAOR (other name)

Answer 19

Treatment sheet

Question 20

How are records filed.

Answer 20

Alphabetically and numerically

Question 21

How often should records be reviewed?

Answer 21

Annually

Question 22

Who is the owner of the record?

Answer 22

The owner of the clinic

Question 23

The most addictive type of drug.

Answer 23

Schedule 1

Question 24

How are drugs monitored?

Answer 24

Controlled substance log

Question 25

Purpose of records?

Answer 25

Support effective treatment and care by documenting all information.