Week 4 Medical Records Flashcards
Standard information that should be found in all patient’s medical record:
Client info, lab and imaging results, sx and an aesthetic records, outcomes from special studies, referral recommendations and even billing and payment info.
The two categories of the functions of the medical record
Primary purposes and secondary purposes
Primary purposes
Supports excellent medical care
Documents communication
Supports continuity of care
Identifies correct patient and owner
Secondary purposes
Supports the business and legal activities
Verifies billing
Supports actuarial calculations
Supports inventory maintenance
Supports formulation of marketing strategy
Supports hospital accreditation
VCPR
Veterinary-client-patient relationship
AVMA’s position on Ethics and Medical records
It is an integral part of veterinary care and must comply with the standards established by state and federal law.
Informed consent
The client was informed of important info, and agreed to pursue a course of action based on the circumstances and info given to him or her. This provides practices with legal evidence that the owner was informed of this important info.
The ‘rules of thumb’ with regards to documentation in medical records:
If it is not written down it didn’t happen. If it is not written down it didn’t happen.
If the writing is illegible, it wasn’t written down.
If one part of the record shows signs of tampering or is inaccurate, the integrity of the entire record becomes questionable.
Basic guidelines for generating accurate medical records:
Entries, typed or written in black ink.
Entries should be signed/initialed, and credentials, date and time entered. Errors, a single line should be drawn through the mistake with the word ‘error’ written in the margin along with the corrected info.
Entries may be initialed rather than signed if the form includes a box with individuals signature listed with the initials.
Only approved, standard abbreviations should be used.
Patient signalment
Information that identifies the individual patient e.g. name, breed, gender, color, chip number, markings etc.
Info that should be obtained for a patient history
Presenting problem; last normal; location in character of the problem; current medications; treatment efforts; comments and concerns of the owner; current diet; recent changes in environment, household schedule, or pets/humans in household; info from previous/referring of it.
Information that should be obtained for previous history
Pets origin; preventative medicine program; behavior; environment; nutritional history; known allergies and reactions; reproduction; previous conditions; medications, treatments and responses; prior referral history.
S.O.A.P
Subjective Objective Assessment Plan
Subjective
Non-measurable info
Objective
Measurable data
