Intro tech history/charting review

what are the first 3 things taking a history can give?

ID the problem, ID possible diagnosis, and determine what tests or exams are necessary (what’s the problem, what is it, what are we gonna do?)

what is Lyme disease?

disease an animal or human can get through an infected tick (L = leach on body = tick)

what are the 2 types of appointments a patient can have and what are their differences?

acute and preventative, acute means their is already a problem so theyre there to find a way to treat it, and preventative means it is routine and theyre there to make sure everything stays right (acute = problem, preventative = prevent)

what types of questions should you ask a client when gathering information and what should you always confirm?

you should ask open ended questions like what brought them in today, and always confirm you have the correct information

how many times should you ask a question?

once, clarify if needed, dont be too pushy because clients can get upset

what should you avoid when asking questions?

medical jargon, leading questions, or repetitive questions (too confusing, know what’s coming next, get angry if too many)

what type of questions give predetermined answers?

leading questions (lead onto next question = clients form own answer)

what should you know before placing a client into a room?

who? (who are they) why? (why are they here) allergies? safety? (do they need special assistance or precautions?)

what type of information is worse than no information at all?

inaccurate information

what is rapport?

relationship of mutual trust and respect (r = relationship)

what is jargon?

technical terminology unique to a particular subject (juggle words)

what are the parts of taking a history?

signalment, background information, medical/surgical history, presenting complaint, last normal, review of body systems. (who are they, medical history, any problems, if any problems when where they last normal, body system questions)

what are 4 reasons why background information is important

ID health risks, help with diagnoses, helps decide treatment, prevents complications (what’s wrong, what is it, what are we gonna do, make sure its right)

three questions you’d asked when gathering background information

what’s your animals health history? what’s your animals surgical or hospital history? is your animal on any medications? (health, surgery, medications)

what are 4 reasons why you should document carefully?

keeps track of pt care, provides legal protection, prevents mistakes, and tracks patient progress (are they okay, have they gotten better, is everything right, make sure its right)

what is SID?

once per day (s= single)

what is BID?

twice per day (bi = 2)

what is TID?

three times a day (ti = tri = 3)

what is QID?

four times a day (q = cuatro = 4)

what is EOD/QOD?

every other day (EO= every other)

what does q mean

every (q = cada = every)

what does qd mean

every day (cada dia)

what does qh mean

every hour (cada hora)

what is the abbreviation for ears

A (audio = hear)

what is the abbreviation for eyes

O (ojos)

what is the abbreviation for left

S (end up on the left after spelling letter)

what is the abbreviation for right

D (derecho)

what is the abbreviation for both

U (unite)

what is PO

per mouth (for ocico)

what is IN

intranasal

how many milliliters is one cc

1

how many mililiters is 1 leter

1000

what is GT

1 drop (gota)

what is GTT

more than 1 drop

what is ADR

aint doing right

what is Rx

prescription or scrip (receta)

what is Tx

treatment

what is Sx

surgery

what is ad lib

as much as desired (a = as much, d = desired)

what is CRT

capillary refill time

what is TPR

temp, pluse, respirations

what does “1 gt artificial tears placed in OU QID/q6hr” mean

1 drop artificial tears placed in each eye every 6 hours

how would you write this “3 tablets tramadol by mouth every 8 hours as needed for pain”

3 tabs tramadol PO q8hr PRN for pain

what is OHE

ovarian hysterectomy

what does SOAP stand for

subjective, objective, assessment, plan

what is SOAP used for

to keep a structured format with pt info

what is VCRP

veterinary client patient relationship

why are VCRPs important

to make sure doctor knows enough about patient to be able to give the correct care

what are some things you should ask when admitting a patient

clinics standard questions (if any), name, reason for visit, flee tick prevention, additional services if needed

things to go over at pt discharge

at home instructions, what to do if any complications

what is a differential diagnosis

all the diseases it could be (different = many)

what are some things that should be found in a hospitalized patients record

working problems list, progress notes, interventions and plans, test results, discharge summary (why are they here, how are they doing, what did you do, what did tests say, what are they going to do at home)