wk 12 Flashcards
(23 cards)
what best describes the primary purpose of a patient medical record?
Provide a historical account of a patient’s healthcare
Because medical records may be used as evidence in a malpractice suit, what is most appropriate to include in them?
Copy of any written communication between the practice and the client
An illegible and incomplete medical record can be viewed by a court of law as
what
Admission of professional incompetence
A veterinary technician makes an error on a medical record. What is the most appropriate way for the technician to correct it?
Strike out the error with one line, make the correction, and place his/her
initials next to it
A good medical record filing system organizes the files by what system?
Alphabetically by clients’ last names or by client numbers
what is the most appropriate way for the clinic staff to organize the medical records of a client with numerous pets?
All in one client file but separated by tabs denoting each pet’s name
what is the ideal way to call team members’ attention to a special note in a medical record?
Place a color-coded sticker on the record.
A client who is contemplating buying a cat from a neighbor, who also happens to
be a client of the practice, calls to ask if the practice will provide a copy of the
medical records for the cat. What is the most appropriate response?
“The client from whom you will buy the cat will have to come in to sign a release form.”
A client calls a practice to request the medical records for a cat that has recently been diagnosed with asthma and that will be taken to a veterinary specialist. What is the most appropriate response?
“We will be happy to send copies of the records to the specialist.”
Every patient of a practice must have a medical record that is legible, well
organized, and complete. What is an additional criterion?
record is easily retrievable
A 14-year-old female mixed-breed dog is brought to the hospital by a passing
motorist who saw the dog by the side of the road. The veterinary assistant
recognizes the dog as a patient who is brought in for wellness examinations
approximately twice per year. The assistant checks the records and dials the owner’s home phone number, but the number has been disconnected. The
assistant recalls that the client works for a local supermarket, calls the market,
and reaches the client. When asked about the disconnected phone number, the client says, “Oh, I haven’t lived in that house for 2 years.” Besides updating the
record with the client’s new phone number, what is the most appropriate course of action?
Reiterate to the staff that client contact information should be verified at
every client visit
What is the name of a summary sheet that includes patient name, gender,
species, breed, age, diet, allergies, vaccinations, and current medications?
Master problem sheet
The veterinarian is monitoring a patient for Cushing’s disease. What document
would be particularly helpful to review?
Diagnostic flow sheet
what is the most commonly used format for medical records?
Problem-oriented medical records
Following the SOAP format, what is most likely to be considered appropriate for inclusion in the “S” section of the POMR?
The owner reports that the dog has become lethargic and is not eating
well
Following the SOAP format, what is most likely to be considered appropriate for inclusion in the “A” section of the POMR?
After reviewing laboratory results and clinical findings, a veterinarian
determines that a dog has intestinal lymphangiectasia
Following the SOAP format, what is most likely to be considered appropriate for inclusion in the “O” section of the POMR?
Palpation of a lump over the right mandible of a dog elicits pain
Following the SOAP format, what is most likely to be considered appropriate for inclusion in the “P” section of the POMR?
A dog’s wound will undergo surgical debridement
what best describes an inactive medical record?
has not been updated in the past year
Most states require that inactive medical records be held for at least a 3-year
period. After 3 years, what is the most appropriate way to discard an inactive record?
Shred them
A radiograph of a patient should include the veterinary hospital’s name and
address, client’s and patient’s names, and the date the radiograph was taken.
What additional information is most appropriate to include?
Left/right indicator
A veterinarian has written the following pharmacotherapy on a medical record: 5
mg diazepam PO. What does this most likely mean in layman’s terms?
5 milligrams of the drug diazepam given orally (by mouth)
A veterinarian has written the following pharmacotherapy on a medical record:
sodium bicarbonate (2 mEq, IV). What does this most likely mean in layman’s terms?
2 milliequivalent of sodium bicarbonate given intravenously
