Veterinary Medical Records

Question 1

a document made up of all handwritten or typed notes regarding the patient, all laboratory data, all surgical and anesthetic records, all client communications, all specialist referrals, and any other documented information regarding that patient

Answer 1

Medical Record

Question 2

List 2 secondary purposes of medical records

Answer 2

Business & Legal Based:
1. Support business and legal activities
2. Support research and development

Question 2

List 2 primary purposes of medical records

Answer 2

Medical Care Based:
1. Support excellent medical care
2. Document communications

Question 3

assists in the conduction of retrospective studies, in predicting clinical outcomes and is used to teach veterinary medical and veterinary technician students

Answer 3

Veterinary Medical Databases

Question 4

the basis for all interactions between veterinarians, their clients and their patients

Answer 4

Veterinarian-Client-Patient Relationship (VCPR)

Question 5

Explain the 5 requirements to claim a VCPR exists

Answer 5

1. The vet has assumed responsibility for the animal’s medical care and the client has agreed to follow the vet’s recommendations
2. The vet has enough familiarity with the animal to formulate at least a preliminary diagnosis
3. The vet is available for follow-up/emergency coverage (or has arranged or such coverage) in the event of an adverse reaction or treatment failure

4.The vet provides oversight of treatment, compliance, and outcome

5. Patient records are maintained

Question 6

ensuring that the client understands all possible aspects of any test or treatment including cost, risks, and expected benefits

Answer 6

Informed Consent

Question 7

a disease that must be reported to government officials because it is dangerous to the public or to widespread animal health

Answer 7

Reportable Disease

Question 8

PIMS

Answer 8

Practice Information Management System

Question 9

Give the 2 primary approaches to medical record organization

Answer 9

1. Source-Oriented Veterinary Medical Record (SOVMR)
2. Problem-Oriented Veterinary Medical Record (POVMR)

Question 10

an approach to medical record organization that groups information by subject matter and keeps records in reverse chronological order

Answer 10

Source-Oriented Veterinary Medical Record (SOVMR)

Question 11

an approach to medical record organization that groups records by problem, with each problem being addressed separately, and notes are recorded in SOAP format

Answer 11

Problem-Oriented Veterinary Medical Record (POVMR)

Question 12

the most recent records being listed first

Answer 12

Reverse Chronological Order

Question 13

What are the 4 components of POVMR?

Answer 13

1. Database
2. Master problem list + working problem
3. Initial plan + progress notes
4. Case summary + discharge instructions

Question 14

consists of all information available about the patient including signalment, history, results of physical examination, laboratory results, anesthetic recordkeeping sheets, and other additional information

Answer 14

Database

Question 15

What 5 things make up databases?

Answer 15

1. Client information/patient’s signalment
2. History - previous/recent
3. Physical exam results
4. Lab results
5. Anesthetic recordkeeping sheets

Question 16

Give 7 important considerations regarding a patient’s history

Answer 16

1. Presenting complaint
2. When the problem started
3. Description of the problem
4. Current medications
5. Current diet
6. Recent changes in environment or household status
7. Other info from client or prior vets

Question 17

WNL

Answer 17

“within normal limits”

Question 18

NSF

Answer 18

“no significant findings”

Question 19

BAR

Answer 19

“bright, alert, and responsive”

Question 20

a compilation of lab values for all tests performed on an individual outpatient or inpatient animal

Answer 20

Laboratory Diagnostic Flow Sheet

Question 21

a document that includes the findings, diagnosis, and recommendations for a patient by a specialty veterinarian and is then emailed to the referring practice

Answer 21

Consultation Form

Question 22

contains a list of all medical disorders experienced by a patient over the course of its lifetime and a final diagnosis for each problem that patient has had addressed in its past

Answer 22

Master Problem List

Question 23

Another name for a Master Problem List

Answer 23

Diagnosis List

Question 24

contains a list of current medical problems and is more focused on clinical signs than diagnosis because a diagnosis may not be known at the time the problem is being addressed

Answer 24

Working Problem List

Question 25

a document that is used to track treatments and diagnostic tests that have been ordered by the veterinarian and may be hung on a patient's cage for quick access

Answer 25

Medication Administration / Order Record (MAOR)

Question 26

MAOR

Answer 26

Medication Administration / Order Record

Question 27

Another name for an MAOR

Answer 27

Ward Treatment Sheet

Question 28

Explain 6 guidelines for MAORs

Answer 28

1. Each order entered should be written exactly as the vet wrote it 2. Person giving the treatment writes their initials in the column to indicate time of administration 3. Clearly note in patient's MR if treatment is NOT given 4. Put an "X" in the boxes representing the dates when the medication was NOT given at a specific period of time 5. Make an entry in a MR if the medication is discontinued 6. Leave remaining boxes blank if full recommended duration of medication was not given due to patient discharge

Question 29

Explain the process for purging medical records

Answer 29

1. Keep records of pets that have been see in the last 3 years out for access 2. Move records of pets that haven't been seen between 4-7 years ago to storage 3. Shred records of pets that have been seen in 8+ years

Question 30

How long are electronic medical records able to be changed?

Answer 30

24-48 hours

Question 31

Once a MR is locked, how are all changes entered?

Answer 31

1. Addendum 2. New note

Question 32

What are the 2 purposes of logbooks?

Answer 32

1. Provide additional documentation for legal support 2. Provide data for quick analysis and retrospective studies

Question 33

Give a few examples of logbooks used by vet practices

Answer 33

1. X-ray 2. Anesthesia/Surgery 3. Laboratory 4. Controlled Substances 5. Ultrasonography 6. Euthanasia 7. Unexpected death 8. Drug reaction 9. Medical waste

Question 34

used to maintain records of vaccinations, reproductive histories, and other information regarding an entire herd

Answer 34

Herd Records