Medical Records VETN 227

A medical record should have a patient’s complete information including ___, ___, ___ findings, ___ tests and results, ___ or ___ reports, ___ studies, ___, ___, and ___ info

owner, history, physical, diagnostics, anesthesia, surgical, special, recommendations, communications, financial

Primary purposes of medical records accurate ___ ___, to generate a ___, using the diagnosis, treatment and response, and the ___ of care

patient ID, plan, continuity

Secondary purposes of medical records ___ activities for all services provided, and for ___ record, because “if not documented, it didn’t happen”

buisness, legal

Medical reconds also have a function as ___ support, with case studies, registries, and veterinary databases

research

Medical records should contain ___ supportive information including ___ and ___

all, diagnosis, treatment

When entering information into the records it should done with ___ and in ___ chronologically, with proper ___, with only standard ___

clarity, order, language, abbreviation

When creating an entry for records to be made with clarity, it should be done by a ___ professional as they understand the case, and properly do so without ___ or ___

veterinary, omissions, repeating

Record entries should be done in order with ___ and ___

date, time

When creating an entry the language should be ___ but ___, and ___ to prevent misunderstandings, and ___ without emotional or editorial tones

concise, thorough, precise, objective

Abbreviations that aren’t ___ shouldn’t be used in medical records as it it can cause confusion

standard

When correcting medical records it should be done with a ___ line through, and with ___ and ___

single, initial, date

Entries should be made in proper locations avoid ___ and between ___

margins, entries

Create entries in a timely or ___ manner to prevent forgetting information

contemporaneous

Entries should be ___ and in ___ ink

legible, black 

All records should contain a ___ with a name, credentials, date, and initials if a signature log exists

signature

VCPR is ___ ___ ___ ___

veterinary client patient relationship

For a proper VCPR the veterinarian should have ___ knowledge of the animal/s, and they assume ___ for them and will use their clinical judgement, treament, follow-up, and oversight

sufficient, responsibility

The VCPR only functions if the ___ agrees to follow instructions

client

Informed consent consists of ___ ___ with understandable language about the diagnosis, prognosis, risks, treatment, aftercare, and costs

full closure

Full closure includes explanations of a patients ___, the ___ of the condition, the ___ with or without therapy, and ___ options, ___, and the ___ and the justification

diagnosis, prognosis, risks, treatment, aftercare, costs

Consent can only given by an ___ that is ___ years or older

owner, 18

A Veterinary practice ___ and ___ medical records

owns, controls

The client or owner can ___ copies of medical records, but its best if it is written and signed

request

Third party releases of medical records must be done with ___ request or permission, and is done via ___ or ___ not by client

client, maiil, electronic 

In some cases ___ agencies or the ___ using a subpoena can access medical records without pemission from clients

govermental, courts

SOVMR is

source oriented veterinary meidcal records

SOVMR is chronologically organized by ___ like physicals, laboratory results, progress notes, etc. 

subject

POVMR is

problem oriented veterinary medical record

POVMR is organized by ___ using ___ notes

problem, SOAP

Things to be included in POVMR records: ___ information, ___, ___ findings, ___, ___ lists, ___

client, history, examination, treatment, problem, summary

When filling out client information don’t assume the ___ of a name

spelling

A client’s contact information includes ___, ___ ___ where they will respond immediately, ___, and best ___ for contact

address, phone number, email, time

History should have the presenting ___ with a history specific to it, and the ___ history, 

complaint, past

PE are formated as ___ notes

SOAP

The datebase should include ___, ___ test and results, ___ flow sheets, ___ reports, ___, and ___ list

PE, diagnositics, anesthesia, surgery, consultations, problem

Working problems are ___ problems which are temporary

temporary

A master problem has an index of history including ___, in chronological ___, ___, and ___

diagnoses, dates, actions, outcomes

The summary in the records should contain the ___, ___/___ and ___

diagnosis, treatments/procedures, prognosis

When discharging there should be instructions ___, ___ specifically diet and exercise, ___ or ___ area, and ___-___

medication, restriction, wound/bandage, follow-up