everything medical records ABH

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Last updated 7:51 PM on 4/24/26
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17 Terms

1
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what are 4 ABVMA complaints (everything medical records)

  1. incomplete records

  2. client communication

  3. details

  4. errors of exclusion

2
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what 6 items are important for all records (everything medical records)

  1. blue/black ink

  2. chronological order

  3. have date and time

  4. initialed by author

  5. all errors crossed with single line and initialed

  6. SOAP

3
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define SOAP (everything medical records)

  1. subjective

  2. objective

  3. assessment

  4. plan

4
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what goes in Subjective in SOAP (4) (everything medical records)

  1. history

  2. symptoms

  3. reasons for being seen

  4. can be completed by RVT

5
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what goes in Objective in SOAP (4) (everything medical records)

  1. vital signs

  2. physical exam

  3. lab results

  4. entered in by anyone, data comes from registered member

6
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what goes in assessment in SOAP (5) (everything medical records)

  1. problem

  2. differential diagnosis - A list of possible conditions that could explain a patient’s symptoms

  3. abnormalities

  4. further testing for diagnosis

  5. DVM ONLY!!!

7
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what goes in plan in SOAP (3) (everything medical records)

  1. tests

  2. treatments

  3. DVM ONLY!!!

8
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what is in tab a at olds college (everything medical records)

patient info

9
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what is in tab b at olds college (everything medical records)

husbandry sheet

10
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what is in tab c at olds college (everything medical records)

treatment sheets

11
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what is in tab d at olds college (everything medical records)

physical exam

12
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what is in tab e at olds college (everything medical records)

lab work

13
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what is in tab f at olds college (everything medical records)

surgery reports

14
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what is in tab g at olds college (everything medical records)

summary sheets

15
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what is in tab h at olds college (everything medical records)

CCAC

16
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what pages are in paitent info at olds college (3) (everything medical records)

  1. release form

  2. master problem list

  3. health certificate

17
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what pages are in treatment sheets at olds college (2) (everything medical records)

  1. treatment sheets

  2. medical records