Veterinary Medical Records

A medical record

a document that has detailed information about the health history of an animal. It also provides details about the owner

The primary purposes of veterinary medical records

are to support patient care and document client communication.

The secondary purposes of medical records

support the business and legal interests of a practice. They can also have implications for veterinary research.

Medical records document the existence of

a VCPR and informed consent

The veterinarian-client-patient- relationship (VCPR)

is the basis for all interaction among vets, their clients, and their patients

The 3 requirements the vet needs to fulfill to claim that a VCPR exists

assume responsibility for the animal’s medical care, be familiar with the animal, and be available to provide follow-up care

Consent forms

typically cover the expected risks and benefits of a procedure. A written estimate, on the other hand, is given to an owner to sign to avoid miscommunications over finances.

When consent is given over the phone

a 2nd witness needs to confirm with the client that informed consent is being given

Informed consent means

ensuring that the client understands all possible aspects of any test or treatment

Accurate medical records

serve as evidence in the case of a lawsuit

Practice information management systems (PIMS) allow

pictures, radiographs, and lab results to be added to the patients records

The source-oriented veterinary medical record (SOVMR)

groups information by subject

The problem-oriented veterinary medical record (POVMR)

groups records by problem. In such a record, each problem is addressed separately in the SOAP format

The American Animal Hospital Association (AAHA) endorses the POVMR

which fosters a team-based approach to patient care

A database consists

of all information available about a patient, this includes a number of distinct components

1st component of the database

client/patient information, includes the patients signalment

Signalment

information that identifies an individual patient, like name, age, sex, reproductive status, and breed

Reportable disease

a disease that threatens public and general animal health and must be reported to government agencies

Previous history includes

information about the animal’s origin, preventative care status, behavior, environment, diet, allergies, and etc.

Recent history

often emphasized unless the patient is new to the practice

WNL

“within normal limits”

BAR

“bright, alert, and responsive”

Laboratory results

section of the database may include results that are automatically transferred into the PIMS from the lab machines

Master problem list

also known as the diagnosis list that includes all major medical disorders experienced by a patient in its lifetime

Working problem list

list of a patient’s current medical problems that the vet team is working through

Hospitalized patient’s records

must be kept updated throughout the duration of the patients stay

SOAP format

medical notes written in the subjective, objective, assessment, and plan format detailing a patients problems

Subjective

contains subjective information such as patient history and subjective impressions, information isn’t measurable

Objective

includes factual, measurable data, such as the animals weight, body temperature, heart rate, and respiration rate

Assessment

describes the steps to correct any abnormalities noted in it

Plan

describes the steps that must be taken to correct any abnormalities notes in the assessment

Medication Administration/Order Record (MAOR)

also known as a treatment sheet, a document to ensure that hospitalized patients are given treatments as requested by the vet

Data organization

most recent information at the top of the record

Must keep all records

updated with the latest information

Alphabetic filing

a filing system in which medical records are filed by clients’ last names

Numeric filing

a filing system in which medical records are filed by a hospital-generated identification number

File purging

reviewing the collection of medical records and purging the records that are no longer in current use, performed anually

Most software allow a record to be

changed in the 1st 24 to 48 hours after an entry is made

Risk of loss of EMRs

during power surges and other electrical disturbances

Logs

these include specific data for a particular hospital department, equipment, or procedures

X-ray logbook

includes info about the client, patient, date, case #, body part being radiographed, machine settings and positioning, etc.

Anesthesia/surgery logbook

details the same info as X-ray logbook, with additional details related to surgery and anesthesia use

Laboratory logbook

provides a synopsis of the lab tests used in the care of patients

Business records of a veterinary practice are usually kept separately from medical records. There may be some overlap if veterinary-specific software links

invoicing to the medical record and history

Food animal veterinarians may maintain

herd records. These records allow them to note information about vaccinations and other treatments given to the entire herd