Exam 5 (medical records)

what information is talked about in informed consent

diagnosis, prognosis, treatment, cost

why is a signature important on an informed consent document

physical evidence that the information was talked about

what are the main things to write on a legal document

credentials, date, time

black ink with legible handwriting

what do you do if you make a mistake on a document

put a single line through it and write error, fix mistake next to it

what can cause you to lose you license

tampering with med records, stealing drugs

what happens if you do the procedure but forget to write it down

if it is not written down, it didn’t happen

who owns the pet’s medical records

the practice owns them, the client can have a copy

what are the exceptions to patient confidentiality

reportable diseases- any disease that can spread to humans (rabies/zoonotic)

what are some components of a vet medical record

client-patient info, history, test results, treatment, examination findings…..

SOAP

subject objective assessment plan

Soap

Subject: vet tech and owner do a casual examination

sOap

Objective: vet tech takes pulse, temp, respiration, vomitus, urination, defecation, blood analysis, lab results, notes on surgical sites or swelling

soAp

Assessment: vet checks out the overall status of the patient, might provide a tentative diagnosis

soaP

Plan: vet provides a diagnosis, prognosis, and a plan of treatment moving forward

what is included in discharge of the pateint

written instructions, any follow up appointments, make the client feel welcome to call with any questions/concerns

why is it important to verbally go over discharge instructions

so the client hears the information and if they have any questions they can ask

when do records go to inactive storage

after 3 years of inactivity

how long are records stored in inactive storage before destroyed

7-8 years then shreded or burned

what are dangerous about lost records

hard to recreate a log, you’ve lost a legal document

general logs

jot down what happened during surgery/radiology/drugs/quick analysis

not a legal document

controlled substance logs

legally required inventory log informing the amount of drugs that have been taken out and used

what type of drugs are considered a controlled substance practice

anything regulated by the DEA

Schedule 1 drugs

most addictive, will never be seen in practice- heroine

schedule 5 drugs

least addictive

schedule 2 drugs

most addictive drugs seen in practice- opioids

how do you store controlled substance drugs

under a double lock and key