Module 3: Medical Records

Medical Records Overview

Module Objectives

  • Understanding the reasons, types, and importance of medical records.
  • Learning how to set up a medical record and the legalities surrounding them.
  • Comparing written and computerized medical record systems.
  • Creating Canadian standard prescription labels and identifying key components.

Readings

  • Chapter 2 – Electronic Medical Records
  • Chapter 3 – Medical Records
  • Chapter 28 – Pharmacology & Pharmacy (up to prescribing and dispensing drugs)

Definitions and Importance of Medical Records

  • Records: Legal documents that serve various purposes in the healthcare context.
Reasons for Medical Records

  • Business

    • Patient Identification: Include identification details for clients and patients.
    • Communication between staff: e.g., details like medications given (e.g., “Fluffy” Tylenol daily) and vaccination records from other clinics.
    • Authorization: Document client-staff agreements on procedures (e.g., owner's consent for dental extraction).
    • Billing: Tracks services rendered and provides a billing framework between staff and clients.

  • Legal

    • Required by law to maintain medical records.
    • Provides legal defense in cases of disputes.
    • Establishes critical legal documents with authorized signatures, quotations, etc.
    • Necessary for tax purposes if the clinic is audited.

  • Diagnostic

    • Facilitates communication among veterinary medical professionals.
    • Utilized for treatment plans, prescription renewals, and behavior notes.
    • Essential for accurate diagnosis, including lab results from bloodwork, X-rays, and ultrasounds.
    • Offers continuity of care via patient history tracking and allows for data collection for client recalls (e.g., vaccine reminders).
Patient Records
  • Must be:
    • Complete
    • Accurate
    • Thorough
    • Legible
    • Follow a logical pattern
      Etiquette: If it is not documented, it is considered never to have happened.

Regulations Governing Medical Records

CVBC (College of Veterinarians of British Columbia) Bylaws
  • Regulations about medical records in British Columbia.
  • Read and familiarize yourself with local laws regarding medical records, especially if relocating from BC.
Important Components of Medical Records
  • Signalment includes:
    • Name, species (e.g., canine), breed (e.g., Smooth Collie), gender/reproductive status (e.g., Neutered Male), age (e.g., 7.5 years), distinctive markings, and electronic ID (e.g., tattoo or microchip).
Required Documents in a Medical Record

A complete medical record should contain:

  • Client information forms
  • Emergency contact forms
  • Client communications
  • Cumulative patient profile/master problem list
  • Examination notes
  • Progress notes
  • Protocol documents
  • Logs (surgery, anesthesia, hospitalization)
  • Laboratory reports
  • Diagnostic images (e.g., radiographs, ultrasounds)
  • Prescriptions
  • Invoices
  • Insurance documents
  • Consent forms
  • Health certificates
  • Rabies vaccination certificates
  • Referral letters
  • Export documents
  • Audit trails of changes made to the record (especially in electronic systems)
  • Copies of records from previous veterinary facilities.
A Comprehensive Medical Record Documents
  1. Client's description of presenting problems.
  2. Findings from physical examination.
  3. Results of diagnostic or laboratory tests, including interpretations.
  4. Problem list with differential/definitive diagnoses.
  5. Description of treatments administered or procedures undertaken.
  6. Future treatment plans.
  7. Advice provided to the client.
Methods of Organizing Medical Records

  1. Source-Orientated Format:

    • Organizes records chronologically per visit.
    • Common in shelters and long-term care; easy to learn.
    • Difficult to review for specific medical problems.

  2. Problem-Orientated Format:

    • Organizes records according to medical problems.
    • Easier to track illnesses.
    • Veterinary software aids navigation (e.g., SOAP format).

Filling Out Medical Records at TRU

  • Each patient requires a dedicated record, including guest surgeries.
General Practices for Record Keeping
  • Proper terminology must be used.
  • All entries must be initialed and dated.
  • Use a 24-hour clock for time entries (local clinic variations apply).
  • Dates formatted as YEAR/MONTH/DAY (local variations apply).
  • Employ the metric system (e.g., kg not lbs).
  • Descriptive records should be thorough but not excessively detailed.
  • Record Retention: Legal requirements specify retention for a minimum of 7 years.
  • Do not use pencils; solely black or blue ink pens are acceptable.
Preferred Format for Comprehensive Records
  • SOAP:
    • S = Subjective
    • O = Objective
    • A = Assessment
    • P = Plan
  • DAP:
    • D = Data (Subjective + Objective)
    • A = Assessment
    • P = Plan
Example Practice Using SOAP Format
  1. Case of Sweet Pea:
    • Patient: Sweet Pea, 8-year-old male neutered Scottish Terrier, 12 kg.
    • Reason for visit: Vaccinations and new scratching behavior.
    • S: Owner's observations noted.
    • O: Vital signs, weight, examination findings.
    • A: Diagnosis and summary (vaccinations, bilateral ear infection).
    • P: Treatment plan for medications, re-examination schedule.
Example Practice Using SOAP Format (Bruno's Case)
  1. Case of Bruno:
    • Patient's characteristics noted, including physical symptoms and results from cytology indicating ear mites.
    • S: Observations and client history.
    • O: Vital signs, cytology results from ear canal.
    • A: Doctor's diagnosis based on findings.
    • P: Treatment plan including medications and follow-up instructions.

Legal and Ethical Considerations

  • Patient records are confidential.
  • The veterinary clinic owns all the original records.
  • Veterinarians must provide clients with access to their pet’s file, with authorization for any third-party sharing.
  • Verbal or written authorization is necessary; document consent in records.
Confidentiality Exceptions
  • Public safety/health risks
  • CVBC requirements or court orders
  • Urgent requests concerning the well-being of an animal
  • Emergency situations requested by government agencies.

Electronic Medical Records

  • Various software systems exist (e.g., Cornerstone).
  • Mostly transitioning toward paperless systems.
  • Functions include invoices, appointment scheduling, and health records.
Comparative Advantages and Disadvantages

  • Advantages:

    • Efficient space utilization, consistent data, quick retrieval, legibility improvements.
    • Enhanced marketing functionalities.

  • Disadvantages:

    • Dependency on power, system glitches leading to data loss, potential inadmissibility in court, coding limitations for detailed descriptions, higher storage requirements.

Prescription and Drug Dispensing

Over-the-Counter vs. Prescription Drugs
  1. Over-the-Counter Drugs
    • Sold directly without DVM authorization.
    • Examples include ear cleaners and non-prescription pet food.
  2. Prescription Drugs
    • Therapeutic agents prescribed by DVMs with a requirement for Vet-Client-Patient Relationship (VCPR).
Controlled Drugs
  • Must be dispensed under prescription only and marked as controlled.
  • Require meticulous record-keeping and proper handling instructions.
Prescription Labels Requirements

The following must be included:

  • Date prescribed, clinic name and contact details, client's name, DVM's name, drug name, quantity and strength, and administration directions.
Remembering Dosages and Directions
  • Common abbreviations (e.g., SID, TID, Q12H) should be noted.