Flashcards in Medical Records Deck (25):
How are records stored?
8.5x11 Manila folders vertically, 5x8 cards in a folder, digitally
Technique of records most clinics use.
Contents of a medical record.
Intake info, lab results, referrals, estimates, vaccine sheets, consents forms, discharge sheets
Each piece of information has its own section of a record.
All information is stored equally and in chronological order in a medical record.
What is included in a database?
Signalment, exams, histories
Chronologically list of major medical disorders of the pet on the front of the medical record.
Master problem list
List of current issue.
Working problem list
Most common format of progress notes.
What does soap stand for?
Subjective, objective, assessment, plan
Presenting complaint/reason for visit. The history from client.
No opinion. The facts about the patient. Physical exam findings, procedures, test results, lab results.
Creating a problem list based on physical exam findings. (ie: bad tarter= dental cleaning). Recommendations
The recommendations to the patient. (Testing, treatment, prescriptions)
What color ink?
Black or blue only
How do you correct mistakes?
Single line through the mistake, write "error" and initial
Written agreements between the veterinarian and the client outlining risks and responsibilities (cost).
Medical administration/order record
MAOR (other name)
How are records filed.
Alphabetically and numerically
How often should records be reviewed?
Who is the owner of the record?
The owner of the clinic
The most addictive type of drug.
How are drugs monitored?
Controlled substance log