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Veterinary Medical Records (Chapter 5) Flashcards

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1
Q

What is a Medical Record?

A

a permanent written account of the professional interaction and services rendered in a valid patient-client relationship

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2
Q

What are the 2 categories of the functions of the medical records?

A

primary purposes

secondary purposes

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3
Q

What are the Primary Purposes of Medical Records?

A

supports excellent medical care

documents communication

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4
Q

Supports Excellent Medical Care

A

assists in correct ID of patient and owner
aids in generation of effective diagnostic and treatment plan
supports continuity of care

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5
Q

Documents Communication

A 
take home instructions
generation of reminder cards
personal information
-financial limitations
-behavioral idiosyncrasies
-future plans
-names of family members
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6
Q

What are the Secondary Purposes of Medical Records?

A

supports business and legal activities

supports research

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7
Q

Supports Business and Legal Activities

A

verifies billing
legal evidence of services received by owner
assesses workloads of staff members
income analysis and budgetary planning
marketing strategies
assesses compliance with standards of care for accreditations

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8
Q

Supports Research

A

preparation of case studies
retrospective studies to help predict clinical outcomes
teaching veterinary students

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9
Q

What are the Cons of Paper Records?

A 
not 100% consistent
legibility is a concern
damaged by fire/water
misplaced
torn, crumpled, yellows with age
large storage space required
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10
Q

What are the Pros of Paper Records?

A

generally easy to use

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11
Q

What are the Cons of Computer Records?

A 
damaged/lost files
power outages
data storage space
initial start up cost
training usually required
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12
Q

What are the Pros of Computer Records?

A

consistent format
easier to access
quickly copied
easily transported

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13
Q

What are the types of Patient Records?

A

letter-size folders
card files
carbonized sheets
computerized

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14
Q

Letter-Size Folders

A

8.5 X 11 inch paper
fastened into a file folder
stored vertically on shelves

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15
Q

What type of Patient Record is the AAHA standard?

A

letter-size folders

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16
Q

Card Files

A

5 X 8 or 10 X 16 inch index cards
filed in pocket folders or card boxes
usually filed in drawers alphabetically

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17
Q

Carbonized Sheets

A

more cost effective and practical for ambulatory and large animal practices
-whole herd records common
one copy of invoice page is given to owner and the other is taken to home practice to be input into computer
laptops are quickly replacing carbonized sheets for record-keeping

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18
Q

What are ways to Organize and File Patient Records?

A

alphabetic by owner last name
numeric by client number
color code system

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19
Q

What is a common mistake made when filiing a patient record Alphabetically?

A

misfilling

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20
Q

T or F: Patient files should be reviewed annually

A

True

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21
Q

T or F: AVMA guidelines require that active records covering a 6 year period be readily accessible

A

False

3 year period

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22
Q

T or F: Texas law states that records covering a 5 year period be readily available

A

True

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23
Q

T or F: Records inactive for 4 years can go into storage

A

True

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24
Q

T or F: Inactive records can be shredded when they reach 10 years of age

A

False

when they reach 8 years of age

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25
What are the types of Formats of Patient Records?
source oriented medical records (SOMR) problem oriented medical records (POMR) combination (problem/source oriented)
26
When are SOMRs typically used?
in records that have limited space, such as in the card or pocket type records
27
How are entries made in SOMRs?
free form
28
What are the Pros of SOMRs?
easy to learn | takes little time to complete
29
What are the Cons of SOMRs?
lack detailed documentation "if its not written down, it didn't happen" forget to write things down hard to find things have to go through "stories" to get information AAHA doesn't like this format
30
Where are POMRs used?
teaching hospitals AAHA-accredited hospitals private practices speciality and emergency centers
31
What does the POMR format help to provide?
provide a whole view of the patient and supports a logical and organized approach to clinical medicine
32
What format must be used in AAHA accredited hospitals?
POMR
33
What do POMRs commonly include?
``` client and patient information history physical exams master problem list and working problem list progress notes, assessment and plan pertinent forms: surgery, anesthesia, radiography, special imaging, and lab reports case summary fee information ```
34
What does a comprehensive history include?
both previous and recent history information
35
When is a comprehensive history taken?
during each new patient visit and during visits from those patients that have not been seen in years
36
What does Previous History Information include?
origin: animal's birthplace and date preventive medicine program: immunizations, parasite control, dental care program, ear care program behavior: usual disposition and temperment, unusual behavioral events environment: kept indoors or outdoors, presence of other pets in home, level of exposure to non-family owned pets, travel history known allergies and reactions: atopy, food, contact with substances, medications, blood transfusions reproduction: neutered, estrus cycles, when bred, number of litters previous conditions, trauma or surgical operations
37
What does Recent History Information include?
``` presenting complaint and circumstances last normal frequency of episodes current meds treatment efforts comments and concerns of owner current diet information from previous or referring vet ```
38
T or F: In the POMR, the signalment, history, physical exam, and diagnostic tests are collectively known as the database
True
39
T or F: In ER and critical care units, the database is considered to include 5 or 6 important pieces of information that are key in treating the critical patient
True
40
What information is included in the database in ER and critical care units?
``` PCV total solids potassium BUN dextrose urinalysis ```
41
What is the Master Problem List?
includes the major medical disorders experienced by a patient during it's lifetime
42
What is the Working Problem List?
assists the technician in working through problems that are relevant to the current hospital stay
43
What does SOAP stand for?
subjective objective assessment plan
44
What are the 2 types of SOAPs?
traditional (used in clinic) | academic (used in schools)
45
S (traditional)
way the patient appears from the point of view of the owner
46
O (traditional)
includes physiologic data such as temp, pulse, respiration | also would note vomitus, urination and defecation and describe color and consistency if applicable
47
A (traditional)
record the status of the patient usually Dr.'s portion where diagnosis and differential diagnosis is
48
P (traditional)
refers to the course of action that will be taken that day | the medication to be given, procedures, and treatment plans are recorded here
49
S (academic)
truly subjective ex: BAR, QAR, weight, behavior, appetite if someone can argue it, it's subjective
50
What is a Differential Diagnosis?
list of things that might be wrong based on owner and physical exam findings
51
O (academic)
``` TPR weight (lbs) BCS lab results current meds ```
52
A (academic)
``` largest part of the SOAP where dx and Ddx belong anything abnormal noted in S and O must be assessed here assess behavior every problem gets a number ```
53
P (academic)
look at assessment every problem needs a plan what is your plan to solve the problems?
54
What are the 2 purposes of logs?
provide additional documentation for legal support | provide data for quick analysis and retrospective studies
55
What are some commonly used logs?
``` radiology log surgery log anesthesia log necropsy log controlled substances log ```
56
What information is included in a Radiology log?
``` patients name and ID number client's name date study type measurement of body thickness technique used: milliamperes (mA), time, kilovolts peak (kVp) radiographic findings or diagnosis ```
57
What information is included in a Surgery log?
``` date animal and owner's name case number patient's weight name of surgeon surgical procedure duration of surgery complications ```
58
What information is included in an Anesthesia log?
``` patient's and owner's name patient's weight relative risk category or result of physical examination anesthetic protocol, including type and dosage of each anesthetic agent anesthesia start and end time number of intubation attempts surgical procedure and name of surgeon anesthetist's name complications ```
59
T or F: An inventory of all controlled substances must be made every 2 years
True
60
What information is included in a Controlled Substance log?
``` date owner's and patient's name starting volume ending volume amount used the initials of the person who used the drug ```
61
How long must all Controlled Substances inventory records be kept?
2 years
62
T or F: The client is by law the owner of their animals medical record
False | they are owned by the hospital or the hospital owner
63
What are the guidelines for generating clear, complete and accurate records?
entries should either be typed or written in black ink in court, handwriting alone isn't an adequate way to identify the author of a notation. entries should be dated and initialed to identify the person making the entry errors should not be scratched out, erased, or blotted out. only approved standard abbreviation should be used
64
How should an error in a patient's chart be corrected?
a single line should be drawn through the mistake and initialed the correct information should then be written in the margin and initialed and dated next to the correction
65
T or F: The medical record is considered legal evidence of services and procedures performed by the veterinary health care team
True

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