Chapter 03 - Veterinary Medical Records

VTHT 1301 Introduction to Veterinary Technology - McCurnin's Clinical Textbook for Veterinary Technicians and Nurses

Serves as legal evidence of services rendered

Which of the following would be considered a secondary purpose of a medical record?

Allows correct identification of patient and owner
Lists physical examination findings
Lists diagnostic procedures performed and results
Serves as legal evidence of services rendered

Juvenile family member

Who is NOT allowed to sign consent forms?

Authorized pet sitter
Owner
Juvenile family member
Co-owner

Signature on initialed entries.

In a court of law, what is the adequate way to identify the author of a notation in a handwritten medical record?

Type of handwriting.
Signature on initialed entries.
Ink color coordination.
It is not a requirement to identify authors of entries in a medical record. The veterinarian is the assumed author.

Draw a single line through the entry and write the word "error" next to it.

What is the proper way to make correction in a handwritten medical record?

Scratch out the error.
Use white out.
Destroy that page of the medical record and start over.
Draw a single line through the entry and write the word "error" next to it.

Physical exam

What is the most important diagnostic procedure performed?

Bloodwork
Physical exam
Radiographs
Ultrasound

Subjective

With regard to SOAP notes, all "nonmeasureable" information falls under which category?

Subjective
Objective
Assessment
Plan

Presenting complaint

Which of the following would NOT be considered an objective finding?

Temperature
Capillary refill time
Presenting complaint
Respiratory rate

Assessment

Hypothermia would be recorded in which portion of the technician's SOAP notes

Subjective
Objective
Assessment
Plan

Completion of patient treatments

What is the MAOR sheet used for?

Completion of patient treatments
Home health care instructions for the client
Log of purged records
Log of control substances used per patient

After 4 years of inactivity

After what length of time can medical records be moved to storage?

After 1 year of inactivity
After 4 years of inactivity
After 8 years of inactivity
Never, they should always be kept on the premises.

After 8 years of inactivity.

When can medical records legally be shredded?

After 4 years of inactivity.
Once the patient is deceased.
After 8 years of inactivity.
Never. They are legal documents.