Week Two: Record Keeping, Computers, and Health Certificates Flashcards
What are the four types of records found in an animal clinic?
Government, financial, inventory, and medical
What is the biggest cost in a clinic?
Payroll
What are examples of government records?
Controlled substance log, OSHA, vet licenses, taxes
What are examples of financial records?
Taxes, books, big inventory (machinery), payroll, insurance billing
How long do we have to keep records for?
Three to seven years (Three in Colorado)
Permanent patient records are owned by who?
The practice
What is tampering?
Changing a medical record in any way
Records can include what?
- Signalment
- Client information
- Important information
- History form
- Physical examination
- Progress notes
- Master problem list
- Working problem list
- Cage cards
What is a signalment?
Description of an animal
What does AWC stand for?
Approach with caution
What is POVMR?
Problem Oriented Veterinary Medical Records
Very detailed, divided into sections (surgery section, lab section, treatment section, phone call and conversation section), filed in reverse-chronological order by date, used in multi vet hospitals
What is a source oriented record?
Chronological order by date
Less time used to organize
What is the most common form of filing system?
Alphabetical
What are some types of filing systems?
Alphabetical Color Numerical Computer Geographical
What are some types of logs?
- Surgery
- Radiology
- Anesthesia
- Necropsy
- Control Substances
- MSDS
- Maintenance
