Medical records

Primary purposes

• Supports excellent medical care​

• Documents procedures and communication

Secondary purposes​

• Supports business activities​

• Supports legal activities​

• Supports research

VCPR

Veterinarian–client–patient relationship

Veterinarian–client–patient relationship (VCPR) exists when:

Veterinarian is personally familiar with the keeping and care of the animal

Informed consent

• Client should be educated before treatment

• verbal and written

• consent & authorization forms signed by legal adult

• fee-estimation forms

Lizzie’s Law (and others) require ___

written prescription consultation when medications are dispensed​

Medical records are owned by who?

Clinic/Practice

SOVMR

Source-oriented Veterinary Medical Records​

POVMR

Problem-oriented Veterinary Medical Records​

What medical record keeping online software does our vet tech program use?

AviMark

SOVMR information from various sources entered in ___ by office visit or hospital stay

chronological order

How is SOVMR paper records organized

ldest information appears first

How is SOVMR electronic records organized

most recent information appears first

What format does Problem-Oriented Veterinary ​Medical Record (POVMR)​ use

SOAP (subjective, objective, assessment, plan)

In POVMR, vets are focused on ___

• cause of illness

• cure

In POVMR, vet techs are focused on ___

patient’s psychological and physiologic reactions to medical condition

SOAP - Subjective

• non-measurable info

• Physical examination

• presenting complaint

SOAP - Subjective examples

• medical history

• Date last “normal” ​

• Location and character of problem​

• Current medications and diet​

• Treatment efforts​

• Owner concerns and comments​

• Information from referring or previous vet

What is the defining part of POVMR

• Master problem list

• Index to patient’s medical history​

SOAP - Objective

• Measurable info

• Physiologic data

• Laboratory data

• Notes on surgical site, catheter placement, swelling, and drainage​

• Pain level scoring if same scale is used across practice

SOAP - Assessment

• Evaluations

• Differential diagnosis

• Analysis of subjective and objective​

• Prioritizes within the hierarchy of needs ​

SOAP - Plan

• Nursing care plan

• Intervention for each evaluation in assessment portion

• Course of action for the day

Notation

Incoming info in progress notes that is independent of SOAP note

MAOR

Medication Administration/Order Record

Medication Administration/Order Record (MAOR)

• Treatment grid

• Summary of patient’s hospital management

Medication Administration/Order Record (MAOR) electronic system

Smartflow

What is not on Medication Administration/Order Record (MAOR)

1. Anesthesia

2. in-surgery meds

   • Separate forms

Discharge and Summary Forms ​

Clear, concise summary of pet’s illness, prognosis, treatment in hospital, and specific discharge instructions

In Discharge and Summary Forms, what are clients educated on?

• signs and symptoms of potential complications

• medications

• diet

• follow-up

• use of equipment

Logs

Legal support and data for analysis

Ambulatory ​Practice Medical Records ​

Usually kept for the herd, not the individual animal