HISTORY and MEDICAL RECORDS

Signalment

Age, Breed, Species, Gender, Repro status (and name)

Importance of Signalment

Identifies the animal

• 5 rights

Legal purposes

• necropsies, neglect cases

Prediction of specific disease

• many diseases associated with species, sec, breed

Why a history is important

Vital diagnostic tool

• allows differentiation between clinical signs

• determines diagnostic tests performed

• Obtains clues to disease

• Establishes a relationship with the client

• Establishes knowledge level of the client

Basic History Guidelines

• Take only as much history as patient's condition allows (emergency?)

• Begin assessing the patient right away. If unstable, take immediately to treatment area!

• Always write down the history

• Be polite and understanding

• Be as detailed as possible

• Observe patient’s behaviors while speaking to the client

• CONTROL THE CONVERSATION

• Never belittle the owner’s concerns

• Adapt to questions to different clients

  • some want facts some don’t

Client differences

Attitudes

• just a dog

• child

• work companion

Cultures

• country

• age

• Socio-economic

Introduction

Always do this first!

• Explain you are obtaining the history to give to the doctor

• Be as friendly and open with the client as you can

  • establish a relationship

  • builds trust

• Clients need to feel comfortable with you

  • allows you to get full and honest answers

  • May inform you of home treatments performed

Routine History

• When and where did they get their pet?

• Vaccine history

• Heartworm testing and prevention

• Parasite control

• Past illness/surgeries

• Diet: what type and how much, any treats?

• Environment: Are there other pets in the home and are they healthy? Indoor/Outdoor

• Current medications

• Last fecal exam

• Travel history

History for Emergency Visits

TRIAGE, TRIAGE, TRIAGE

• Much shorter than a wellness history

• Obtain a brief explanation of what happened

  • gather vital signs while listening to owner

• Stabilize the patient first

  • gather a more complete history later

• Keep owner updated on status

Common clinical signs of disease

Lethargy

Anorexia

Vomiting

Regurgitation

Diarrhea

Polyuria/Polydipsia

Weight loss or gain

Skin issues

Skin and Haircoat - History

Hair loss

• How long?

• Has it gotten worse or better?

Changes in coat appearance:

• When did it start?

• Did anything change when you noticed a difference (environmental, food, other animals)

Itching:

• When did it start?

• Certain time of year?

• Other environmental factors?

Area of redness:

When did it start?

Environmental changes

Heart and Lung issues - History

Sneezing

• What time of day?

• Ocular or nasal discharge

Coughing

• What time of day?

• Productive vs. non-productive

• exercise?

Dyspnea

• inspiratory or expiratory?

• Exercise?

Syncope (fainting)

• Exercise?

• Level of consciousness

Gastrointestinal - History

Diet

• How is their appetite?

• How they eat (too fast, dropping food)

Water consumption

• Too much (polydipsia)

• too little

Weight

• loss/gain/maintaining

Hypersalivation

Vomiting/Regurgitation

• Active or passive actions

• After food/water

Fecal Scores

• Presence of parasites

History of foreign body ingestion

Urinary Tract - History

Drinking more (polydipsia) or less?

Frequency increased (pollakiuria) or decreased

• Increased amount (PU)

• decreased amount? (oliguria)

• None? (anuria)

Discoloration?

• Bloody? (hemturia)

• Orange? (bilirubinuria)

• Green? (can be caused by propofol use)

Smell

Incontinence

• Frequency

• Dribbles or puddles

• Occasionally normal

Straining (stranguria)

Green urine

Can be caused by propofol use

Male Reproductive Tract - History

Sex status

Breeding

• libido?

• Success

Preputial discharge?

Lumps?

Testing

Female Reproductive Tract - History

Sex status

Breeding

• Last Bred?

• Last litter?

• Number of litters

• Success”

Heat cycle?

Discharge?

Changes in urine?

Difficulty whelping in the past?

Musculoskeletal - History

Lameness

• Which leg(s)

• Weight bearing or non-weight bearing?

• Intermittent or persistent?

• Better or worse with activity?

• Improving, worsening or staying the same?

History of trauma?

History of previous surgeries on affected limb?

Weakness or ataxia?

Eyes - History

Vision changes?

Bumping into objects?

Discharge?

Blinking/squinting/winking?

Appearance of eyes?

Ears - History

Hearing?

Shaking the head?

Rubbing or scratching?

Painful?

Discharge?

Odor?

Status of other pets?

Neurological - History

Mentation change

Behavior change

Seizures?

• Length

• Frequency

• Patient consciousness

• Any vomiting/defecation/urination?

Weakness (paresis)

Inability to ambulate (paralysis)

Onset of symptoms?

History of trauma?

Getting better or worse

Medications

Behavior - History

Housebroken?

Inappropriate elimination?

Changes in sleep/wake patterns?

Loss of hearing?

Aggression?

Fear?

Socialization changes?

Change in daily behavior?

Oral Care - History

Brushing

• Toothpaste?

• Oral rinse?

Oral care diet/treats?

Eating/chewing habits?

Appetite

Dropping food?

When learning to take a history

• Learn to identify differences

• Tailor your question to get the most/best information from the client

• Learn to spot what is working and what isn’t

• Be flexible enough to change

• Takes practice

• Develop a script to follow so you don’t miss vital information

Purpose of Medical Records

Continuity of care

• Vets and nurses understand full medical history

• Allows for informed decisions

Legal document

• In case of disputes or legal matter

Protective measure for clients and staff

• Shields from misunderstandings

• Shields from liability

Included in a medical record

Written notes                               Other images

• SOAP                                      Laboratory results

Radiographs                                Designated owner

Ultrasound images                      Releases

Video recordings                          Waivers

Photographs                                 Vaccination records

Microchip information

Medical Record Legal requirements

State regulations: vary by state

Federal guidelines

Retention requirements

Timeliness

• need to be updated immediately after each visit

• Prevents gaps in documentation

Legal document!

• Monitors patient progress

• Information can be retrieved quickly

• Keep all staff up to date no status of patient

• Blue or black ink ONLY

Medial record Legal Documents DONTs

Use pencil

Erase information

White out information

Scribble to mark something out

Ownership of Records

Practice Ownership

• Most regions

Client right

• Right to access, not ownership

• Can request copies

Transfer of records

• Can be shared with other veterinary professionals

• Especially for specialty care

Importance of client privacy

• Practice must protect client information

• HIPPA doesn’t apply to animals

  • no federal regulations

  • Pet considered property

  • professional ethics

• Breach in privacy?

  • Legal consequences

  • fines and damage to reputation

Record Security

Control Access

• Only authorized personnel should access records

• Train employees

Digital records

• use encryption software

• Create backups to prevent data loss

• Comply with local digital privacy laws

• Implement lock-out after # of login attempts

Paper records

• Store in locked cabinets

  • limit key access

  • should be water/fireproof

• Don’t leave unattended

Requires securing

Client info: Name, Address, Contact numbers

Medical: Health details, Past conditions, Treatments, Medications

Financial Data: Billing records, Payment records, Saved credit card info

Sensitive notes

Record Retention

Indiana requires veterinarians to maintain records for 3 years after last encounter

• Same duration for deceased patients

• Vets can be fined if non-compliant

Record disposal

• Shredding, burning, etc.

• Not legally required in vet med

Record-Keeping standards

Stay consistent

Utilize SOAP

Be objective

• avoid opinions

• Document facts and observable behavior

Document, Document, Document

• phone calls, in-person conversations, EVERYTHING

SOAP

Subjective - what the owner reports and what staff observe that cannot be measured

Objective - quantifiable data and exam findings

Assessment - Diagnosis or differential diagnoses based on findings

Plan - treatment plan, further testing, follow-up instructions

Subjective

• Information that cannot be measure of quantified

• Provides context for objective findings

• Client explains symptoms

  • change in behavior, eating habits, activity levels, etc.

• Vet staff observes the patient

  • attitude, stress discomfort, demeanor

Subjective example

“Owner reports that the dog has been lethargic and less interested infood over the past 3 days”

Objective

Measurable, quantifiable data

• PE values, body weight, observable physical symptoms

• Lab test results

• Imaging results (x-ray, ultrasound, CTs, MRIs)

Provides factual evidence that supports future treatment

Objective example

“Temperature: 103.5 F, Heart Rate: 120bpm, Respiratory rate: 24rpm”

“Mild lameness observed in the right hind limb; palpable swelling in the abdomen”

What category of SOAP is the physical exam

Objective

Assessment

Integrates subjective and objective findings

• leads to diagnosis or diagnoses (differentials)

Vet will:

• Identify main problem and contributing factors

• Analyze interaction between issues that exist along with changes

• Diagnose the problem(s)

• Form an explanation

• Discuss it with owner

Assessment Example

“Primary assessment: Gastroenteritis, likely due to dietary indiscretion.”

“Differential diagnosis: Possible arthritis in the right hind limb or soft tissue injury”

Plan

Outlines the nest steps

• Vet team and client

May include:

• Additional tests

• Medications

• Dietary changes

• Other treatment modalities

• Follow-up schedule

• Client instructions

Plan example

“Start on antibiotics (Amoxicillin 10/mg/kg BID for 7 days) and anti-inflammatory medication as needed. Recommend follow-up in 5 days to assess response to treatment.”

“Owner instructed to withhold food for 12 hours, then introduce bland diet (boiled chicken and rice). If vomiting persists, return for further evaluation.”

Benefits of SOAP

Consistency

Organized approach to care

Can be easily referenced in the future