Medical Records

Question 1

What is a medical record

Answer 1

Legal documents
Must be kept confidential
ECG, radiographs,lab results are property of the hospital
Vets and techs should document everything on record
Mistakes should not be erased

Question 2

Formats of medical records

Answer 2

Source oriented
POVMR

Question 3

Source oriented Medical records

Answer 3

Old school hand written
Recordings by vets, techs & assistants
Info filled in reverse chronological order

Question 4

POVMR

Answer 4

Client/patient info
History
Physical exam
Problem/progress list
Pertinent forms
Case summary
Database

Question 5

SOAP notes

Answer 5

Subjective-history
Objective- exam
Assessment- diagnostics/more info/plan
Plan

Question 6

M/N & Male

Answer 6

Male neutered/ male intact

Question 7

F/S or Female

Answer 7

Female spayed or female intact

Question 8

TPR

Answer 8

Temp, pulse, respiration

Question 9

CRT

Answer 9

Capillary refill time

Question 10

Dx

Answer 10

Diagnosis

Question 11

Rx

Answer 11

Prescription

Question 12

Sx

Answer 12

Surgery

Question 13

Hx

Answer 13

History

Question 14

Fx

Answer 14

Fracture

Question 15

NSF

Answer 15

No significant findings

Question 16

WNL

Answer 16

Within normal limits

Question 17

ADR

Answer 17

Ain’t doing right

Question 18

FNA

Answer 18

Fine needle aspirate

Question 19

BAR

Answer 19

Bright alert responsive

Question 20

QAR

Answer 20

Quiet alert responsive

Question 21

CSVD

Answer 21

Coughing/sneezing/vomit/diarrhea

Question 22

FUO

Answer 22

Fever of unknown origin

Question 23

PU/PD

Answer 23

Polyuric/polydipsic

Question 24

NPO

Answer 24

Nothing by mouth

Question 25

SID

Answer 25

Every 24 hrs

Question 26

BID

Answer 26

Every 12 hrs

Question 27

TID

Answer 27

Every 8 hrs

Question 28

QID

Answer 28

Every 6 hrs

Question 29

EOD

Answer 29

Every other day

Question 30

PRN

Answer 30

As needed (pro re nata)

Question 31

PO

Answer 31

By mouth (per os)