Clinical records

Question 1

To whom are clinical records important to?

Answer 1

• The patient
• The vet
• The client
• The veterinary team
• The scientific community
• Legal and professional bodies

Question 2

What are the main reasons of importance of clinical records for the vet?

Answer 2

Ensures all information is available to correctly assess, diagnose and treat the patient. Allows progression to be seen and if any changes in treatment are required. Allows them to be fully informed.

Question 3

Whose property are clinical and client records including diagnostic images?

Answer 3

The property of the veterinary practice

- clients have a right to access the information

Question 4

What information should be kept seperate from clinical notes?

Answer 4

Financial, personal or sensitive information

- A statement that treatment has been declined on financial grounds is acceptable.

Question 5

Describe some factors that should always be undertaken when writing clinical notes

Answer 5

• written at the time of the events
• amendments should be made clear
• clear and accurate
• use of medical terms and abbreviations correctly
• records should be factual and should remain objective

Question 6

What should be avoided when writing clinical notes?

Answer 6

1. Removing erroneous information
2. Blank spaces
3. Errors of omission
4. Use of second hand data

Question 7

What does SOAP stand for when using this approach to writing notes?

Answer 7

S = Subjective
O = Objective
A = Assessment
P = Plan

Question 8

What is subjective data?

Answer 8

Includes the demographic data about the patient, known as the signalment. Includes: age, species, breed, sex, and reproductive status

Question 9

For the soap approach at which point should a thorough history be undertaken?

Answer 9

As a part of subjective data

Question 10

What are examples of objective data?

Answer 10

• Temperature, pulse and respiration (TPR)
• Weight
• Capillary refill time
• Body condition score
• Physical exam findings related to body systems – have a system for this and document appropriately
• Results of diagnostic imaging
• Laboratory findings
• Blood pressure

Question 11

What is the purpose of the assessment?

Answer 11

Provides an interpretation of the subjective and objective data to help formulate a problems list - includes appropriately prioritising the,

Question 12

Which 3 main aspects as encompassed in the plan?

Answer 12

1. diagnostic recommendations
2. therapeutic recommendations
3. client communication