Video: Veterinary Medical Records, Behavior, and Restraint - Key Concepts Flashcards

Practice-ready, concise QA flash

What defines a Veterinarian-Client-Patient Relationship (VCPR) according to the AVMA, and what conditions must be met?

The AVMA defines a VCPR as: the veterinarian has assumed responsibility for making clinical judgments and the client agrees to follow instructions; the veterinarian has recently seen and is personally acquainted with the animal by examination or timely visits; the veterinarian is readily available or has emergency coverage; the veterinarian provides oversight of treatment and outcome; and patient records are maintained.

What are the Primary Purposes of the Veterinary Medical Record?

Identifies the correct patient and owner; documents diagnostic procedures, diagnoses, prognoses, and treatment plans; supports continuity of care; documents communications with the client; supports reminders for preventive care; personalizes the VCPR.

What are the Secondary Purposes of the Veterinary Medical Record?

Billing verification; supports business analysis (income, budgeting, staffing); supports inventory maintenance and marketing; supports accreditation; serves as a legal document; supports research (case studies, registries, databases) while protecting confidentiality.

Who owns veterinary medical records, and how can clients access them?

Medical records are the property of the practice and its owners. Clients may request copies of their pet’s records in writing; HIPAA does not cover pet records, but some states have privacy laws similar to HIPAA. Access is granted through authorized release with written consent, and records are released carefully, often directly to the new veterinarian.

What is the difference between Source-Oriented VMR (SOVMR) and POVMR?

SOVMR organizes information by subject matter (e.g., labs, progress notes) with chronological history shown; POVMR groups information by problem and uses SOAP notes for each visit, improving focus on diagnosis and treatment of specific problems.

What are the components of a Problem-Oriented Veterinary Medical Record (POVMR)?

1) The Database (initial data like client/patient info, history, exam findings, tests); 2) Master Problem List and Working Problem List; 3) Initial Plan and Progress Notes (SOAP for visits, MAORs, surgical and anesthesia forms); 4) Case Summary and Discharge Instructions.

What is the Master Problem List in POVMR?

A master list of major medical disorders experienced during a patient’s lifetime, typically arranged with date of onset, actions taken, outcomes/resolutions, and outcome dates; serves as an index to the medical history.

What is the Working Problem List in POVMR?

A dynamic list used to organize current problems during hospitalization; may include problems that are symptomatic or provisional until a final diagnosis is made; helps prioritize care.

What is the Database in POVMR (the POVMR components)?

A collection of information contributing to the diagnostic process, including client/patient information, history (current and previous), physical exam findings, test results, and other relevant data.

What does SOAP stand for in veterinary notes, and what is each part?

S: Subjective (non-measurable information, owner’s descriptions); O: Objective (measurable data such as vitals, tests); A: Assessment (clinical reasoning and diagnoses); P: Plan (interventions, treatments, and client education).

What is MAOR in the hospital record, and what information does it contain?

Medication Administration/Order Record; records which treatments were delivered, when, and by whom; includes medication name, dose, route, time, and any cautions; can be paper or electronic and may also feed into billing.

What is the role of Cage Cards in hospitalized patients?

Cage/ward cards identify the patient and reason for hospitalization; may use color codes to indicate hospital division (e.g., red for surgery, blue for internal medicine) and help organize patient care.

What is the Emotional Medical Record, and why is it important?

A record of a patient’s emotional state and preferences for handling, distractions, and communication strategies; used to tailor handling to reduce fear and improve welfare and care outcomes.

What are the Touch Gradient and its two main components?

A method of touching animals to reduce fear: 1) maintain continuous hands-on contact during procedures; 2) gradually increase touch intensity while monitoring acceptance; start with less sensitive areas and progress.

What is the Considerate Approach in Fear Free care?

An approach to handling that minimizes fear and stress by environment setup, distraction choices, pheromones, soothing communication, safe handling, and clear client communication (Table 5.10 outlines strategies).

What is the Fear, Anxiety, and Stress (FAS) score, and how is it used?

A numeric scale from 0 to 5 assessing a patient’s fear, anxiety, and stress during care; 0-1 is calm (green light), 2-3 is moderate (yellow), 4-5 is severe distress (red). Guides decisions about proceeding or altering care plans.

What are Happy Visits and Victory Visits in Fear Free care?

Happy Visits are non-medical visits offering treats and comfort to reduce stress; Victory Visits involve planned sessions to habituate the patient to veterinary care using conditioning techniques.

What is the ABC model of behavior in veterinary behavior work?

A: Antecedent (stimulus preceding behavior); B: Behavior (the action); C: Consequence (the result that reinforces or discourages the behavior).

What are Desensitization (DS) and Counterconditioning (CCC) in behavior modification?

Desensitization gradually exposes the animal to a feared stimulus at non-stressful levels; Counterconditioning replaces the fear response with a positive response (e.g., treats). When combined (DS-CC or DS-CCC), effective behavior change can be achieved.

What are the two main timing options for classical conditioning or counterconditioning?

Backward conditioning, simultaneous conditioning, delay conditioning, and trace conditioning; each has different benefits and challenges in delivering the conditioned stimulus and reward.

What is the purpose of the Master Problem List vs Working Problem List in practice?

Master Problem List records final diagnoses over the patient’s lifetime; Working Problem List tracks ongoing clinical problems during current care to prioritize treatment and nursing care.

What is Box 3.3 AVMA Ethics and Medical Records about?

An excerpt emphasizing ethical handling of medical records, confidentiality, and the importance of maintaining patient markers and an ethical standard in keeping and using medical information.

What are the key elements of the 'Repository' for Veterinary Medical Records?

Include the patient ID, signalment (species, breed, age, sex, reproductive status), owner contact, history (origin, preventive care, medications), presenting complaint, diagnostic results, treatment plans, and discharge instructions. Privacy and access controls are essential.

What is the role of Consent and Authorization Forms?

Written documentation of informed consent: outlines conditions, risks, responsibilities, and describes the course of action; confirms owner understanding and agreement, and can protect against liability.

What are Box 3.4 Standard Information for Veterinary Medical Records about?

A reference box listing standard information to collect in medical records, including client/patient information, signalment, history, physical findings, diagnostic results, and discharge instructions.

What is the importance of Records Auditing and Audit Trails in EMRs?

Audit trails automatically record changes, addenda, and deletions; ensure the integrity of the primary document and help prove unauthenticated alterations would not be admissible in court.

What is a SOVMR, POVMR, and the hybrid approach mentioned in the notes?

SOVMR: Source-oriented by subject matter; POVMR: Problem-oriented organized by problems with SOAP entries; Hybrid: combines elements of both approaches in some systems.

What is the purpose of Logs in veterinary EMR systems?

Logs record department-specific data (surgery, anesthesia, diagnostics, etc.) and provide documentation for legal support and enable retrospective analyses.

What is the role of 'Scribe, ChatGPT, or AI-powered tools' in medical records?

They can be used to assist with documentation, but the ultimate responsibility for accuracy lies with the veterinarian.

What is the 'Policy on Data Privacy' for pet medical records?

Pet records are generally owned by the practice; clients may request copies; HIPAA does not cover pets, but states may have privacy rules; release requires written consent and is restricted to protect confidentiality.

Why is 'informed consent' critical and what are the three standards?

To ensure owners understand diagnoses, prognosis, risks, and costs before consenting; standards: 1) reasonable practitioner, 2) reasonable client/patient, 3) individual client/patient.

What is the 'format' priority for presenting medical information to clients and courts?

Clarity, accuracy, objectivity, using standard abbreviations, chronologic entries, and avoiding editorial language; entries should be signed/dated and follow contemporaneous documentation principles.

What is the significance of 'telemedicine' in the VMR and VCPR context?

Telemedicine can support VCPR in some contexts, but many states require in-person or timely follow-up to establish/maintain a VCPR; telemedicine status varies by state and evolving practice acts.