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Flashcards in Medical Records Deck (25):
1

How are records stored?

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

2

Technique of records most clinics use.

Computer stored

3

Contents of a medical record.

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

4

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

Problem orientated

5

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

Source orientated

6

What is included in a database?

Signalment, exams, histories

7

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

Master problem list

8

List of current issue.

Working problem list

9

Most common format of progress notes.

Soap

10

What does soap stand for?

Subjective, objective, assessment, plan

11

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

Subjective

12

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

Objective

13

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

Assessment

14

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

Plan

15

What color ink?

Black or blue only

16

How do you correct mistakes?

Single line through the mistake, write "error" and initial

17

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

Consent form

18

MAOR

Medical administration/order record

19

MAOR (other name)

Treatment sheet

20

How are records filed.

Alphabetically and numerically

21

How often should records be reviewed?

Annually

22

Who is the owner of the record?

The owner of the clinic

23

The most addictive type of drug.

Schedule 1

24

How are drugs monitored?

Controlled substance log

25

Purpose of records?

Support effective treatment and care by documenting all information.