Inventory, SOP, and Records

what does POMR stand for (Medical Records)

Problem Oriented Medical Record

how is POMR organized (Medical Records)

It organizes information in the record by problem

POMR includes (10) (Medical Records)

1. Date

2. Presenting complaint

3. Pertinent history

4. Patient evaluation, exam findings

5. Problem(s) listed

6. Assessment of the complaints, the history and the problems in order to come up with a tentative diagnosis or rule outs

7. Refine the problem list, develop a plan of action, implement the plan and re-evaluate

8. Diagnostic and therapeutic plans

9. Medications prescribed or administered with amount, dosage, frequency and duration as indicated on prescription label.

10. Prognosis in complex or serious cases

how is a Source Oriented Medical Record done (Medical Records)

This is a chronological narrative that is organized only by the source of the information.

what are specific requirements for paper records (5) (Medical Records)

1. Staff Initials are key when entering

2. needs confirmation of attending staff member who completed.

3. No blanks or scribbling or white-out

4. for errors, use single line to cross out and initial

5. if writing, has to be BLUE or BLACK pen only

what is always required on a medical record (9) (Medical Records)

1. Client Information

2. Signalment

3. recent weight

4. Written Information/Client communication

5. Dates & Times

6. Radiograph images

7. Ultrasound Images

8. Laboratory results

9. Medical files on treatment from another facility

If it isn’t in the medical file … (Medical Records)

It didn’t happen

how long are legal documents Required by law to be maintained for (Medical Records)

5 yrs

ABVMA requirements (7) (Medical Records)

1. Identify patient and client

2. Adequately maintained (especially hospitalized patients)

3. Entries in chronological order

4. EVERY entry must be initialed

5. Errors must be crossed out with a single line and initialed

6. System must allow for prompt retrieval and access

7. Maintained for 5 years

what verbal communication should be recorded (6) (Medical Records)

1. any conversation

2. Telephone calls

3. Clients stopping by clinic in person for updates or visits

4. Emails

5. Text messages

6. These entries must include who was in the conversation, as well as the content of the conversation.

When can you transfer medical records (Medical Records)

ONLY if paitent consents or wants them

what does SOAP stand for (Medical Records)

1. subjective

2. objective

3. assessment

4. Plan

define subjective (SOAP) (Medical Records)

is the Data obtained from the client or veterinary team member about the patient

define objective (SOAP) (Medical Records)

is Measurable data

define Assessment (SOAP) (Medical Records)

Diagnosis made after assessing ‘S’ and ‘O’

define plan (SOAP) (Medical Records)

is Based on ‘A’ and Decided by the veterinarian

define AI (Medical Records)

AI is technology that enables computers and machines to simulate human learning

Incomplete medical records can lead to (7) (Medical Records)

1. cause you to lose your license, the Vet’s license and the clinic

2. contribute to inaccurate quality and care information

3. cause lost revenue/reimbursement

4. result in poor patient care by other healthcare team members

5. result in inappropriate billing leading to charges of fraud

6. interfere with patient-client relationships

7. compromise safe patient care

what does REFLECT stand for (Medical Records)

1. R - recognize assumptions (patient cause),

2. E - explore alternatives,

3. F - fight bias,

4. L - look for patterns,

5. E - evaluate pros/ cons of current communication style,

6. C - consider worst case to patient,

7. T - turn to others to seek input

what does SOP stand for (SOP’s)

Standard Operating Procedures

define SOP (SOP’s)

a detailed, written set of instructions or guidelines that outlines the steps to complete a particular organizational task or process

Important steps of writing a SOP (6) (SOP’s)

1. Understand the purpose and scope

2. Gather information

3. Structure the SOPs

4. Writing the SOPs (template)

5. Review and approval

6. Implementation and training

define objectives (SOP’s)

Clarify the purpose of the SOPs. Are they for clinical procedures or administrative tasks?

define Scope definition (2) (SOP’s)

1. Determine which processes or tasks will be covered by the SOPs.

2. Identify the departments or individuals involved.

define Process identification (SOP’s) (2ish)

1. List all the processes that need SOPs.

2. This may include patient intake, billing procedures, scheduling appointments, and handling medical records.

define Interview the team (SOP’s)

Talk to the team members who perform these tasks to understand current practices, challenges, and potential improvements.

what under Understand the purpose and scope (SOP’s)

1. define objectives

2. scope definition

whats under gather information (2) (SOP’s)

1. process identification

2. interview the team

whats under Structure the SOPs (SOP’s)

1. header

2. Consistent outline

define header (includes 4) (SOP’s)

Include

1. the title

2. date written

3. the revision date

4. revision number if applicable

define Consistent outline (SOP’s)

Provide a clear outline of the document’s contents for easy navigation—and use the same template for every SOP to ensure consistency.

what in an SOP template (10) (SOP’s)

1. Start with a clear objective/purpose

2. Job levels

3. definitions

4. Health or safety warnings

5. Equipment/materials/tools

6. Step-by-step instructions:

7. Include visual aids:

8. Responsibilities

9. Quality control measure

10. References

define Job levels (SOP’s)

List the job titles of those who should be able to perform the task

define definitions (SOP’s)

Define any abbreviations used in the SOP, considering a new hire who may not be familiar with industry abbreviations.

whats under Review and approval (SOP’s)

1. Internal review

2. Revision

define Internal review (SOP’s)

Have the practice owner(s), medical director, and manager(s) review the SOPs for accuracy and completeness.

define revision (2) (SOP’s)

1. Incorporate feedback from the team

2. make necessary revisions.

whats under Implementation and training (3) (SOP’s)

1. Rollout plan

2. Training

3. Documentation

define Rollout plan (SOP’s)

determine how and when the SOPs will be implemented.

define training (SOP’s)

Conduct sessions to ensure the team understands and can follow the SOPs effectively.

define documentation (SOP’s)

Keep records of training sessions and ensure all team members acknowledge receipt of the SOPs

what SDS stand for (SOP’s)

Safety Data sheets

what on an SDS (6) (SOP’s)

1. product name (trade and generic)

2. Company name/identification

3. hazards - eye contact, skin exposure, ingestion, irritant

4. Main ingredients

5. first aid measures - VERY important

6. Accidental release measures

what is it (SOP’s)

flammable

what is it (SOP’s)

explosive

what is it (SOP’s)

flammable

what is it (SOP’s)

corrosive

what is it (SOP’s)

compressed gas

what is it (SOP’s)

harmful/irritant

what is it (SOP’s)

toxic

what is it (SOP’s)

health hazard

what is it (SOP’s)

biohazardou infectious materials

what are the 2 most expensive parts of the clinic (Inventory Control)

1. inventory

2. payroll

important weekly inventroy control checklist (4) (Inventory Control)

1. check volume of product

2. check expiry dates

3. “when in doubt, ask the Vet / Owner”

4. write needs, etc. on the control sheets

main system of pharmacy organization (3) (Inventory Control)

1. Arranged by physical form

2. Alphabetical by trade name or by company name

3. Arranged by therapeutic use

Factors that can affect drug stability (4) (Inventory Control)

1. Time (expiry dates)

2. Moisture

3. Light

4. Temperature

what to do with meds part expiry date (Inventory Control)

1. place red sticker on it

2. remove

how long are meds stable for if no expiry date (Inventory Control)

3 yrs

what temp should refrigerated drugs be (Inventory Control)

Between 2 to 8 degrees Celsius

what temperature should room temp drugs be (range) (Inventory Control)

15 and 30 degrees Celsius

Signs of instability of drugs (4) (Inventory Control)

1. Precipitate formation

2. Colour change

3. Cloudiness

4. Broken emulsions, will not re-suspend when shaken

what are the 4 distribution centres (Inventory Control)

1. AVP

2. WDDC

3. CDMV

4. compound companies

how to order drugs/products (5) (Inventory Control)

1. Make a list

2. Place the order

3. Check your cart before submitting

4. If ordering drugs/ medications, check for the SU beside that product, this could indicate a case lot discount.

5. Check back orders

how to order controlled drugs (2) (Inventory Control)

1. It is the responsibility of the DVM to order the narcotics

2. Someone needs to sign for it.

what to do when recieving shipment (8)(Inventory Control)

1. Check for breakage

2. check for frozen product upon arrival

3. Count number of packages/crates

4. Must sign for shipment if all packages are present and in good order

5. Record any errors

6. File packing slip after everything checks out OK

7. Check invoice against packing slip

8. Final step, price, code and put stock away.

Inventory Control review of pills/tabs (Inventory Control)

count them

Inventory Control review of medicated liquids (2) (Inventory Control)

1. eyeball volume

2. measure

Inventory Control review of food and med supplies (Inventory Control)

count them

how to dispose of drugs (4) (Inventory Control)

1. Return to manufacturer for proper disposal, if possible

2. crush tablets and dispose of in waste

3. Biologicals should be incinerated

4. USE A BIO WASTE DISPOSAL COMPANY