Veterinary Medical Records: Introduction

What is the purpose of a medical record in veterinary practice?

To provide a permanent account of interactions and services rendered to a client.

What are the key characteristics that a medical record must have?

It must be accurate, up to date, legible, and created for each patient treated.

How long must medical records be kept on file after a patient's last visit?

A minimum of 3 years, though some states require 5-7 years.

What ink colors are acceptable for writing medical records?

Records must be written in blue or black ink.

What is the correct procedure for making corrections in a paper medical record?

Single line through the entry, date and initial the error, and write the correct information next to it.

Who owns the medical records?

The veterinarian or hospital treating the patient.

What are the benefits of computerized medical records?

Access from any computer, cloud-based access from any location, and the ability to upload diagnostics and scan documents.

What concerns are associated with computerized medical records?

System security against hackers and employee theft, alteration of records, and initial investment costs.

What methods should be used to prevent loss of data in medical records?

Daily backups, using multiple backup methods (CD/DVD, external hard drive, cloud), and both on-site and off-site backups.

What information should be included in a medical record?

Client/patient information, communications, estimates and consents, previous medical history, vaccination history, primary complaint, physical exam, treatments, diagnosis, referrals, laboratory results, prognosis, and surgical reports.

What specific details must be recorded for vaccines and injections?

Name, amount, volume, route, and location of the vaccine/drug.

What should be included in client discharge instructions?

Information about diet, activity restrictions, and a verbal review of instructions before providing documents.

What is the importance of legibility in medical records?

Records must be easily readable to ensure accurate communication and documentation.

What are the different filing methods for medical records?

Records can be filed by client last name, number, alphabetically, numerically, or in a paperless database.

What is the role of a backup system for medical records?

To ensure data can be restored in case of theft, fire, or other disasters.

What is the significance of having detailed visit information in medical records?

It serves as a legal document for reference in case of disputes or for future treatment.

What should be done if a veterinarian moves from California regarding medical records?

Check the laws of the new state for record-keeping requirements.

Why is it important to have clients initial discharge instructions?

To confirm that they received and understood the information provided.

What is the purpose of including a previous medical history in a medical record?

To provide context for current treatments and decisions.

What does the acronym SOAP stand for in veterinary medical records?

Subjective, Objective, Assessment, Plan

What is the purpose of the Subjective section in SOAP notes?

To include the reason for the visit, observations made by the client, and history information such as onset, length, and severity of symptoms.

What type of data is recorded in the Objective section of SOAP notes?

Factual data collected from the patient, including vitals, physical exam findings, and diagnostic results.

What should the Assessment section of SOAP notes include?

Conclusions reached from the subjective and objective sections, including a diagnosis, differential diagnoses, rule-outs, tentative diagnosis, and definitive diagnosis.

What is the Plan section of SOAP notes used for?

To outline treatments, surgery, medications, follow-up visits or diagnostics, and planned communications.

What must be included in a medical record according to the notes?

Physical exam, differentials, diagnosis, lab interpretation, prognosis, progress notes if hospitalized, all treatment and surgery notes, and all medication information.

What is the purpose of the Client Patient Information Form?

To collect information when a new client/patient is seen for the first time or when client information has changed.

What is the function of the Physical Exam Form in veterinary practice?

To record data from a complete physical exam, often using multiple different exam forms.

How should Progress Notes and Treatment Plans be organized in a paper record system?

They should be placed in chronological order, with the most recent on top.

What types of observations can be recorded in Progress Notes and Treatment Plans?

Observations and progress notes during treatments, including TPRs (temperature, pulse, respiration), weight checks, and tech appointments.

What is the significance of the 'per Dr.' notation in the Assessment and Plan sections?

It indicates that the information is documented as per the directive of the attending veterinarian.

What should be done if a treatment is performed by a veterinary technician?

The technician must write up the information and initial it.

In what section of the medical record should client communications be recorded?

Objective

What does the term 'differential diagnosis' refer to in the context of veterinary assessments?

A list of potential diagnoses that could explain the patient's symptoms.

What is meant by 'rule-outs' in veterinary assessments?

Conditions that are considered but are not confirmed as the diagnosis.

What is included in the 'Objective' section of a SOAP note?

Factual data such as vital signs, physical exam findings, and diagnostic results.

What is the importance of the Assessment section in SOAP notes?

It summarizes the findings from the subjective and objective sections and helps in forming a diagnosis.

What is the role of the Plan section in veterinary medical records?

To outline the next steps in treatment, including medications, follow-ups, and any necessary surgeries.

What is the significance of chronological order in medical records?

It helps track the progression of the patient's condition and treatment over time.

What should be done if a client's information changes?

The Client Patient Information Form should be updated.

What types of treatments might be included in the Plan section of SOAP notes?

Medications, surgeries, and follow-up diagnostics.

What is the purpose of surgery/anesthetic forms?

To record surgical procedures and monitor anesthesia.

How should laboratory work be filed?

In chronological order, with the most recent on top.

What is a Master Problem List?

A history of an animal's past and present medical conditions, becoming obsolete as practices move to electronic records.

What miscellaneous forms are commonly used in veterinary practices?

Treatment Sheets, Discharge Instructions, Authorizations (surgery, anesthesia, euthanasia, record release), and others as needed.

What should be included on the right side of medical records?

Progress notes and treatment plan (SOAP form), physical exam forms, and notes for grading.

What is typically found on the left side of medical records for office procedures?

Client/Patient Information Sheet.

What forms are included on the left side for shelter animals?

CPAS / ARWOB rabies form, shelter animal summary sheet, lab work, surgery forms, anesthesia reports, and client/patient information sheet.

What forms are included on the left side for resident animals?

weight chart, lab work, surgery forms, anesthesia reports, and client/patient information sheet.

How should the forms be arranged in a medical record?

Client/Patient form on the left, physical exam form on bottom right, SOAP form on top right.

What is the significance of the Master Problem List in veterinary practices?

It provides a comprehensive history of an animal's medical conditions but is becoming less common due to digital records.

What is the purpose of treatment sheets in veterinary practices?

To document ongoing treatment and care for patients.

What are discharge instructions used for?

To provide pet owners with information on post-treatment care.

What is the role of authorizations in veterinary practices?

To obtain consent for procedures such as surgery, anesthesia, and euthanasia.

What is the importance of proper labeling in medical records?

To ensure easy identification and organization of records for both clients and staff.

What is the expected layout for a medical record for a pet?

Client/Patient form on the left, physical exam form on bottom right, SOAP form on top right.