Quiz 11: Medical Records Management

A client calls the practice to request medical records be released to a specialist for a cat that has been diagnosed with asthma. Which of the following is the most appropriate action?

The client must sign a waiver form in order to provide copies of the records to the specialist.

A veterinary office uses a computer-based medical record management system that normally works well. However, one day a computer virus strikes the system and it is shut down for repair. Because the office cannot function without the computer system, the practice must cancel the rest of the day’s appointments. Which of the following would have been most appropriate to do as a backup plan should the clinic’s computers become temporarily unusable?

Preload available laptops as backups with the proper software.

Which of the following is the most commonly used format for medical records?

Problem-oriented medical records

A veterinary technician makes an error on a medical record. Which of the following is the most appropriate way for the technician to correct it?

Strike out the error with one line, make the correction, and place team member initials next to it.

Because medical records may be used as evidence in a malpractice suit, which of the following is most appropriate to include in them?

Copy of any written communication between the practice and the client.

What is the name of a summary sheet that includes patient name, gender, species, breed, age, diet, allergies, vaccinations, and current medications?

Master sheet or master/problem list

Following the SOAP format, which of the following is most likely to be considered appropriate for inclusion in the “A” section of the POMR?

After reviewing laboratory results and clinical findings, a veterinarian determines that a dog has intestinal lymphangiectasia.

A veterinarian has written the following pharmacotherapy on a medical record: 1.5 mg diltiazem PO. Which of the following accurately describes these instructions?

1.5 milligrams of the drug diltiazem given orally.

Following the SOAP format, which of the following is most likely to be considered appropriate for inclusion in the “P” section of the POMR?

A dog’s wound will undergo surgical debridement.

An illegible and incomplete medical record can be viewed by a court of law as which of the following?

Admission of professional incompetence.

Most states require that inactive medical records be held for at least a 3-year period. After 3 years, which of the is the most appropriate way to discard an inactive record?

Documents must be shredded

Which of the following is the ideal way to call team members’ attention to a special note in a medical record?

Place a color-coded sticker on the record

Which of the following is the most appropriate way for the clinic staff to organize the medical records client with numerous pets?

All in one client file with a tabbed separation denoted for each pet

A veterinarian has written the following pharmacotherapy on a medical record: sodium bicarbonate (2 mEq. IV). Which of the following accurately describes these instructions?

2 milliequivalents of sodium bicarbonate given intravenously

Which of the following best describes an inactive medical record?

A record that has not been updated in the past year

Which of the following best describes the primary purpose of a patient medical record

Provides a historical account of a patient’s health care

A client is contemplating adopting a cat from a neighbor, who also happens to be a client of the practice, calls to ask if the practice will provide a copy of the medical records for the cat. Which of the following is the most appropriate action?

The current owner of record must sign a release form for copies to be released