Veterinary Medical Records

A ___________ should be maintained in such a manner that another veterinary professional could, by reading it, easily understand the case and proceed with proper care of the patient.

Medical records

Interaction between veterinarians and their clients and patients is conducted under the ___________, and medical records must be maintained for all patients with whom this relationship exists.

Veterinary-client-patient relationship (VCPR)

Through the use of the ________ veterinary medical record, an organized approach to clinical veterinary care is achieved, as information is grouped by problem and each problem is addressed individually.

Problem-oriented

The _________ veterinary medical record is a medical record format in which patient information is grouped by subject matter and clinical observations are entered as they become evident.

Source-oriented

The _________ refers to the collective information that identifies an individual patient, such as the species, breed, gender, reproductive status, age, color, and distinctive markings.

Signlment

Recorded information, such as a patient’s date of birth, preventive medicine program, behavior, previous conditions, and known allergies, is included as part of the _________ in a comprehensive medical record.

Previous history

A structured system of documenting patient evaluation and assessment in the progress notes is called the ________ format.

SOAP

Patient information, such as presenting complaints, current medications, location and character of problems, treatment efforts, and recent changes in the environment, may be included as part of the ___________ in a comprehensive medical record.

Recent history

Major medical disorders experienced by a patient during its lifetime are included in the ________ list, which serves as an index to the patient’s medical history.

Master problem

Veterinary practices will often use the _______ list to assist the veterinary health care team when working through current patient problems.

Working problem

The ongoing daily management of hospitalized patients is documented in ____________ so that therapeutic treatment and plans may be evaluated and adjusted accordingly.

Progress notes

Hypothermia, altered mentation, inappropriate elimination, and risk of infection ______________, according to the veterinary nurse practice model.

Veterinary nurse evaluations

To ensure that a hospitalized patient is given the treatments, diagnostic tests, and diet requested by the veterinarian, the ___________, or ward treatment sheet, is used.

MAOR (medication administration/order record)

A _________ is a collection of all available information that would contribute to the diagnostic process of a patient when originally seen for a particular problem.

Database

Temperature, weight, capillary refill time

Objective

Awake, standing, wagging tail

Subjective

Limited daily exercise, cold compresses to injury

Plan

Heart rate, respiratory rate, skin retraction time

Objective

Cardiac insufficiency, hypotension, decreased perfusion

Assessment

Antibiotics prescribed, hypoallergenic diet, follow-up appointment

Plan

Anxiety, panting, reduced mobility

Assessment

Lethargic, not eating well, lying in right lateral recumbency

Subjective

Bleeding gingiva, halitosis, difficulty chewing

Priority 5 - Nutrition

Body temperature of 94°F, acute abdominal pain, chemistry panel K+ = 1.2 mmol/L

Priority 2 - Critical Safety and/or Severe Pain

Anxious, fearful, displays submissive urination

Priority 9 - Utility

Deep sores caused by licking and scratching at ears; owner won’t use an Elizabethan collar as directed.

Priority 6 - Noncritical safety

Restless at night, gets up slowly, pants heavily when exercised

Priority 8 - Activity

Dyspnea, blue mucous membranes, oxygen level 89% on pulse oximetry

Priority 1 - Oxygenation

Delayed recovery of skin tenting, weak peripheral pulse, tacky mucous membranes

Priority 3 - Hydration

Moaning frequently, reluctant to move, tail tucked between legs

Priority 7 - Chronic Pain or Mild-Moderate Acute Pain

Urinating in the house, urinating more frequently, unable to hold urine overnight

Priority 4 - Elimination

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. The medical record can be used as a legal document in a court of law and can be of critical importance in defending against malpractice suits.

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Completed consent and authorization forms provide veterinary practices with legal evidence of informed consent and can be signed by a pet owner of any age.

False

Consent and authorization forms must be completed by legal adults age 18 years or olderolder.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Entries in written records may be corrected using correction fluid, provided the entry is signed and dated by the person who made the error, with a brief explanation of the correction.

False

Errors should have a single line drawn through them and the word “error” should be written in margin along with the corrected information. The change should also be signed and dated by the person who made the error, and a brief explanation for the correction should be entered.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Only approved, standard abbreviations should be used in medical record keeping.

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Veterinary medical records are the property of the pet owner because the client purchased the veterinary services that generated the medical information.

False

In general, veterinary medical records are the property of the veterinary practice and its owners. Although the client purchased the veterinary services that generated the medical information, the client is not, by law, the owner of the medical record.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. The owner of an animal should not be required to sign an authorization form to obtain a copy of his or her pet’s record if it is only for himself or herself.

False

It is considered best practice to obtain a signed authorization form or a written letter or request for request for record copies from the animal’s owner before any information is releases to the owner, another veterinarian, or another third party.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. If a veterinarian diagnoses a reportable disease, permission from the client to release the patient’s record must be obtained prior to alerting local, state, and federal agencies.

False

If the veterinarian has diagnosis a reportable disease, information in the medical record must be given to the appropriate authority without client permission.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. In general, the hard copy MAOR is preferred to the electronically generated one.

False

The advantages to an electronic MAOR include legibility, retrievability from any computer, and visibility to multiple patients simultaneously. In some platforms, additional benefits include the indication that a treatment is completed as a date, time-stamped patient record entry and the capture of billing information.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. The American Animal Hospital Association (AAHA) endorses the use of problem-oriented medical record-keeping for practices seeking AAHA certification

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. When recording physical examination results, abbreviations such as “BAR” and “WNL” should not be used because they may be interpreted differently by other veterinary health care providers.

False

Use standard abbreviations such as BAR and WNL supports and accurate medical record keeping.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. The POVMR working problem list helps veterinarians and veterinary technicians think critically, identify and prioritize problems, and formulate an understanding of the patient’s reactions to an illness.

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Medication administration/order records should include the patient’s full name, patient I.D. number and/or signalment, and any known allergies that the patient may have.

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. When documenting treatments on an MAOR, an “X” should be placed in the appropriate column at the time the medication is administered to the patient.

False

When documenting treatments on the MAOR, the initials of the person giving the treatment should be placed in the column.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Medications given during surgical or anesthetic procedures should be entered on the MAOR along with all other medications that the patient receives.

False

Medications given during surgical or anesthetic procedures should be entered on surgery or anesthesia forms, not on the MAOR.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. When using the alphabetic system of medical record filing, a major disadvantage is that a client cross-reference list must be generated and maintained.

False

In the alphabetic system, a different color is iven to each letter of the alphabet and the first few letters of the client’s last name used to label the patient’s chart. The system is easy to learn and does not require cross-referencing with a master list of clients.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. The American Animal Hospital Association requires that paper records for each patient be stored in standard letter-sized folders.

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. The primary medical record collection should include active records covering a three-year period (or other period established by the practice).

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. A recommended practice for purging files is to remove and shred all records that have been inactive for four years or more.

False

Records that have inactive for four or more are moved to storage. Records eight years old or older may usually be removed from storage and shredded, although state requirements must be met.

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. To ensure confidentiality and integrity, AAHA standards include the provision that the electronic medical record system automatically closes record notations after a user-specified period (maximum of 24 hours).

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Consistency with paper records can be improved with use of exam forms, labels, or stamps.

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. A log is a hard-copy document noting specific procedures.

False

A log can be either hard copy or electronic

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Two of the advantages of the numeric filing system are that fewer filing errors occur because numbers are easier to read and interpret than letters, and spelling is not a factor.

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Practices must keep 12 different types of logs.

False

A large practice may have up to eight to 12 different types of logs; small practices may have two to four logs

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Voice recognition software can be used in the examination room, doctor’s office, and/or operating room.

True

Read the following statements and write “True” for true or “False” for false in the blanks provided. If a statement is false, correct the statement to make it true. Although ambulatory practitioners may make handwritten notes on carbonized invoice sheets to be transcribed upon return to the office, many carry a mobile device such as a laptop or tablet to assist with record keeping.

True

In what way does the POVMR provide a more organized approach to clinical veterinary care than a SOVMR?

The informations in the medical record is grouped by problem and eash problem is assigned a number and addressed separately.

Although the POVMR includes SOAP notes that may be written by both veterinarians and veterinary nurses, the focus of their assessments is different. How does the focus of these assessments differ? 

The veterinarian focuses on identifying the cause of illness and subsequently a cure, while the veterinary nurse focuses on the patient’s psychological and physiologic reactions to the medical condition.

What are the four general components most commonly included in the POVMR? 

i. Database

ii. Master Problem List and Working Problem List 

iii. Initial Plan and Progress Notes

iv. Case Summary and Discharge Instructions

The working problem list is an important component of the POVMR that helps the veterinary healthcare teamwork through current problems. Explain the difference between the master problem list and the working problem list. 

The master problem list includes the major medical disorders experienced by a patient during the lifetime, serving as an index of the patient’s medical history. The working problem list is an active tabulation of clinical problems and symptoms generated by the veterinary nurse and veterinarian.

Why is it important that any entries in the discharge summary that indicate future care be documented accordingly, whether performed or not?

Any entries in the discharge summary that indicate future care (i.e. recheck in 5 days) should be documented accordingly, whether care was performed or not. If not performed and not document, it will give the appearance of a gap in care.

6. Ambulatory food animal and equine practitioners typically do not transport lengthy medical record files during their travels. Discuss different approaches they may use for record keeping.

Although some ambulatory practitioners still continue to make handwritten notes on carbonized invoice sheets or other methodology to be transcribed into the actual record upon return to the office, many carry a mobile device such as a laptop ot tablet computer in their vehicles to assist with record keeping. The practitioner enters information about diagnosis, treamtment, and billing with the mobile device. Based on the practitioner’s practice management system, actress may be real-time through a wireless internect connection or mobile hotspot. Alternatively, in the absence of internet connection, a “check out” copy of the practice database is used and is later syncthronized back into the main database upon return to the office. Some ambulatory practitioners use an index of bar codes, each one representing a different diagnosis, procedure, or medications. The veterinarian scans the appropriate bar codes to create an invoice and to document the diagnosis and treatments rendered, instructions to the owner might also be generated. The information can be either emailed on site or lantern or printed out using a portable printer in the vehicle.

The plan for patient care is an accumulation of interventions developed by the veterinary nurse for each evaluation listed in the assessment portion of the SOAP.

a. What is the ultimate goal of developing a patient care plan?

b. Give several examples of the general types of interventions that would be considered part of the care plan. 

a. The goal for the patient care plan is to restore patient comfort and well-being.

b. Client education, moderate daily exercise, administration of medications as ordered by the attending veterinarian, daily cold compresses, and follow-up appointments are examples of interventions that are part of the care plan.

POVMR discharge instructions provide pet owners with the information and resources to continue any prescribed homecare and monitoring of their pet. Summarize the information and procedures that should be included when discharging a hospitalized patient, so that a desirable outcome for both the patient and owner may be achieved.

A clear, concise summary of the pat’s illness, prognosis, and treatment during hospitalization and specific discharge instructions are written in simple language that the client can understand. A  Printed copy of the form id given to the owner or reviewed on the computer with the veterinary nurse and the owner before the animal leaves the hospital. It is advisable to have the client sign the form to achnowlefge receipt of the infomtation, a copy of the signed form to remain in the office. One-on-one communication offers an apporitunity for the pet owner to ask questions and allows the burse to ensure the appropriate care of the pet will be continued at home. In this way, the veterinary nurse directly educates the pet owner about the pet’s disease process and the clinical signs and symptoms of potentuak complications. Take-home instructions regarding administration of medications or special diet or feeding instructions, use of Elizabethen collars, and recommended follow-up exams or tests, for example, are also discussed directly with the client. For further edification of the client, preprinted instructional brochures or handouts may be attached to the instructions, or all forms and informational content may be emailed. The veterinarian nurse’s name and clinic contect information are foten included on the form so that the owner can call if questions or problems arise.

What are the two primary purposes of a medical record?

Supporting excellent patient care and documenting client communications.

What are the three requirements for a VCPR to exist?

The veterinarian has assumed responsibility for the animal’s medical care, and the client has agreed to follow the veterinarian’s recommendations. The veterinarian has either recently examined the individual animal, or examines the animal’s premises on a regular basis. The veterinarian is available for follow-up/emergency coverage (or has arranged for such coverage).

What’s the meaning of “informed consent”?

Informed consent means ensuring that the client understands all possible aspects of any test or treatment, including costs, risks, and the expected benefits.

List the four sections of a SOAP note.

Subjective, objective, assessment, plan

Paper medical records can be filed according to two systems. What are these two systems?

Alphabetical filing, numeric filing

Describe how records of differing ages are handled when purging files.

The records of patients seen within the last three years should remain in the active records. Patients last seen between four and seven years ago should have their records moved to storage. Records can be discarded if the patient was last seen eight or more years ago.

What is the advantage of a numeric filing system?

One of the advantages of the numeric filing system is that fewer filing errors occur because numbers are easier to read and interpret compared with letters, and spelling is not a factor. In addition, numeric filing systems are practical for large-volume practices because no file supplication occurs, whereas in the alphabetic system, many clients may have the same surname. An added benefit is also the protection of client identification since it’s not readily visible from the external record folder.