Medical Records

Definition

  • Medical Record

    • A legal document that records sequential health events each time the patient is seen by the veterinarian

    • Summarizes the patient's medical history

      • Illness

      • Symptoms

      • Past treatments

      • Medications

Purpose

  • Provides continuity

    • Current veterinarian

    • Multiple veterinarians

  • Offers quick, easy access to information

    • Vaccinations

    • Master problem list

  • Gives financial history

    • Receipts from past visits

  • Serves as a legal document

    • Confidential

Legal Documentation

  • Medical records are owned by the veterinary practice

  • The attending veterinarian is authorized to release medical information only to other practices

  • Hand written with blue or black ink

  • Maintaining files

    • Inactive files are removed and stored

  • Purging files

    • Eliminate hard copies after seven years

Filing Systems

  • Numerical Filing

    • Each fluent or specific patient is assigned and filed by a specific account number

    • Color Coding

      • A color is assigned to numbers 0 to 9

  • Alphabetical Filing

    • Each client is filed alphabetically by owner’s last name, first name, middle initial and patient name

    • Color Coding

      • Color is assigned to specific letters

Creating Medical Record

  • Client Information

    • Name

    • Address

    • Telephone Number

  • Patient Information

    • Name

    • Species

    • Breed

    • Age

    • Gender

    • Reproductive Status

    • General Physical Description

Organization of Medical Information

  • Source-Oriented Medical Record (SOMR)

    • Data kept in chronological order

    • Data organized based upon subject matter

    • Normally written in narrative format

  • Problem-Oriented Medical Record (POMR)

    • Data kept in reverse chronological order

    • Data organized based upon progress notes for each visit

    • Normally written in note/list format

Problem-Oriented Medical Record

  • Contains the following

    • Master Problem List

      • Contains dates associated with health issues that the client reported or that the veterinarian observed

    • Progression Notes

      • In SOAP format

        • Subjective, Objective, Assessment, Plan

          • Subjective Information

            • Non-measurable clinical impressions of the patient

          • Objective Information

            • Factual, measurable data

          • Assessment

            • Diagnosis compromised from diagnostic testing and physical examination

          • Plan

            • Treatment that is recommended