Chapter Vocabulary Review: Veterinary Medical Records, Behavior, Restraint, and History/Physical Exam

POVMR (Problem-Oriented Veterinary Medical Record)

A medical record format that groups information by problem and uses SOAP notes for each problem, fostering organized, team-based care.

SOVMR (Source-Oriented Veterinary Medical Record)

A record organized by subject matter with information like lab reports and progress notes stored separately; historical data are usually chronological with the most recent entries last.

Master Problem List

A comprehensive list of the major medical disorders experienced by a patient over its lifetime, usually with date of onset, actions taken, outcomes, and resolution dates.

Working Problem List

A dynamic, current list of clinical problems used during hospitalization to guide care before final diagnoses are established.

Database (POVMR context)

The initial collection of all information for a patient that contributes to the diagnostic process (history, exams, tests, etc.).

SOAP notes

A structured format for medical documentation: Subjective (non-measurable info), Objective (measurable data), Assessment (professional conclusions), and Plan (course of action).

VCPR

Veterinarian-Client-Patient Relationship; a formal relationship where the veterinarian has responsibility for medical judgments and patient care, knowledge of the patient, availability for follow-up, and maintained records.

MAOR

Medication Administration/Order Record; a ward treatment sheet used to document what treatments were given, when, by whom, and to summarize patient management.

EMR (Electronic Medical Record)

A digital version of a patient’s medical record that replaces or complements paper records, supporting accessibility, legibility, and audit trails.

HIPAA

U.S. Health Insurance Portability and Accountability Act; applies to human health records but many states have similar privacy laws that affect veterinary records; confidentiality is maintained.

Consent and Authorization Forms

Written documents describing agreed-upon treatments, risks, costs, and responsibilities; used to formalize informed consent and reduce liability.

Informed Consent Standards

Three standards: reasonable practitioner, reasonable client/patient, and individual client/patient; determine what must be disclosed for consent.

Informed Consent (oral and written)

Consent that includes full disclosure of condition, risks, alternatives, and costs; should be documented in the medical record.

Ownership of Medical Information

Medical records are typically the property of the practice; clients may request copies, but records ownership rests with the practice.

Confidentiality

Protection of patient information; third-party releases require client permission, with exceptions for