Veterinary Medical Records

Veterinary Medical Records

Records that contain information regarding the veterinary care and treatment of animals.

Purposes of the Medical Record

Supports excellent medical care, documents procedures and communication, and facilitates business, legal, and research activities.

Veterinarian-client-patient relationship (VCPR)

Exists when the veterinarian takes responsibility for clinical judgments and is familiar with the care of the animal.

Ownership of Medical Records

Veterinary medical records are owned by the practice, but clients may order copies.

Source-oriented Veterinary Medical Record (SOVMR)

A record format where information is entered chronologically by office visit or hospital stay.

Problem-oriented Veterinary Medical Record (POVMR)

A record format that uses the SOAP method and focuses on patient problems and treatments.

SOAP format

An acronym for Subjective, Objective, Assessment, and Plan used to organize medical records.

Master Problem List

An index to a patient's medical history, including major medical disorders experienced during its lifetime.

Working Problem List

A list used to address current problems in patient management.

Electronic Medical Records (EMRs)

Digital records that improve legibility, consistency, and reduce risk of loss with additional features like templates.

Security of EMRs

Standards and practices to protect electronic medical records, including automatic closing and off-site storage.

Paper Medical Records

Traditional records that do not require power but can be easily misplaced and are accessible by one person at a time.

File Purging

The process of reviewing and discarding medical records based on established guidelines, typically at least once a year.