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Veterinary Nursing > History Taking > Flashcards

History Taking Flashcards

1
Q

What is the legal importance of medical records?

A

-It’s a legal document so it can be used in a court of law
-If you didn’t write it, it didn’t happen
-NY maintains records for 3 years after last visit

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2
Q

What is the medical importance of a medical record?

A

-Prior history
-Clarity

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3
Q

How should entries be made in a record?

A

-Black ink
-Errors crossed out with one line and initialed
-Date every entry
-Initial every entry

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4
Q

What should the patient record include?

A

-Basic info on the client
-Basic info on the patient

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5
Q

What is basic client info?

A

-Name
-Spouse name
-Address
-Place of employment
-Phone number
-Email

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6
Q

What is basic patient info?

A

-Name
-Record number
-Signalment
-Species
-Breed
-DOB
-Sex
-Reproduction status

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7
Q

What is signalment?

A

A detailed description for purposes of identification

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8
Q

Shorthand for male

A

M

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9
Q

Shorthand for female

A

F

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10
Q

Shorthand for neutered male

A

MN

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11
Q

Shorthand for spayed female

A

FS

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12
Q

Shorthand for vaccination

A

Vx

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13
Q

Shorthand for history

A

Hx

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14
Q

Shorthand for diagnostic testing

A

Dx

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15
Q

Shorthand for physical exam

A

PE

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16
Q

Shorthand for treatment

A

Tx

17
Q

Shorthand for surgical

A

Sx

18
Q

Shorthand for medications

A

Rx

19
Q

What does SOAP stand for?

A

Subjective, Objective, Assessment, Plan

20
Q

What falls under the subjective category?

A

-Qualitative assessment: how the patient appears
-BAR (bright, alert, responsive)
-QAR (quiet, alert, responsive)

21
Q

What falls under the objective category?

A

-Quantitative assessment: measurable data
-TPR: temperature, pulse, respiratory rate

22
Q

What falls under the assessment category?

A

-Concerns and differential diagnosis
-Completed by vet

23
Q

What falls under the plan category?

A

-Diagnostic plan
-Treatment plan
-Done by a vet

24
Q

What is a symptom?

A

Changes in bodily functions that are reported by a patient

25
Q

What is a sign?

A

Clinical findings noted by a medical professional (animals only have signs)

26
Q

What needs to be included in the history?

A

-Signalment
-Weight
-Diet
-Water consumption
-Urination
-Past medical history
-Medications currently taking
-Allergies
-Environmental history
-Exercise
-Work
-Behavior

27
Q

What needs to be included in past medical history?

A

-Vaccination history
-Past medical problems
-Permission to obtain records from previous vet(s)

28
Q

What needs to be in the history of present problems?

A

-Cheif complaint/ presenting problem
-Onset
-Frequency
-Trigger
-Duration
-Progression
-Relief

Veterinary Nursing (12 decks)

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