medical records notes

Medical Records Management

  • Definition
    • Permanent account of the interaction and services rendered to a client.
    • Provides accurate information.
    • Must be complete and legible.

The Purpose of Medical Records

  • Supports Excellent Medical Care

    • Uniquely identifies clients and patients, preventing confusion of similarly named clients.
    • Documents communication with clients, including:
    • Signed treatment plans and authorization sheets.
    • Take-home instructions.
    • Phone logs of communications.
    • May document behavioral idiosyncrasies of patients.
    • Critical accuracy and completeness for potential malpractice suits.

  • Supports Business Activities

    • Invoices/services received by clients/patients and payment records.
    • Determines staff workload for budgeting.
    • Handles inventory maintenance.
    • Acts as a legal document in court against malpractice suits.
    • Importance of complete records noted due to ineffectiveness of index card records.

  • Supports Research

    • Data from medical records forms case studies.
    • Develops registries and databases (e.g., OFA).
    • Used in the education of veterinary medical students.

Accuracy of Medical Records

  • Legibility

    • Importance of records being readable by all team members.
    • All medical records must be accurate and complete.

  • Key Areas of Use

    • Referrals.
    • State veterinary boards.
    • Court systems.

Helpful Items for Medical Records Management

  • Increase Legibility
    • Utilize computerized medical records.
    • Incorporate stamps, stickers, and labels for better management.
    • Bright alert stickers to draw attention to special needs patients.

Legal Requirements

  • Writing Specifications

    • Must use ink (blue or black), not pencil.
    • Correction fluid is prohibited.
    • For mistakes: cross through the error, make correction, and initial.

  • Patient Records

    • Each patient must have their own medical record (records may be kept in one owner file).
    • Exception: Medical records for herds/flocks can be grouped.
    • Storage of paper records typically in 8 × 10-inch folders.
    • Storage location varies by practice size (near receptionist or dedicated records room).
    • Color coding facilitates easier filing and prevents misfiling.
    • Accuracy in Filing: Extremely important.

Medical Records & Confidentiality

  • Confidential Nature
    • Medical records are confidential and can only share patient information during care.
    • Personal client information cannot be disclosed.
    • Medical records are property of the veterinary facility, not the client or veterinarian.
    • Must be retained for a minimum of 3 years post last visit.
    • Summary of medical records to be provided within five days upon client request.

Record Keeping (§ 2032.3)

  • Mandatory Content
    • Must include: animal history, physical exam information, treatment plans, medications, dosages, route of administration, surgical records, diagnoses, prognosis (if relevant), daily progress, case disposition.
    • Name or initials of the person responsible for entries must be included.

Medical Records as Legal Documents

  • Documentation Standards
    • Patient and owner's name on each page.
    • Permanent entries, no alterations allowed (no pencil, white out, only black or blue ink).
    • Corrections must be made by crossing out with a single line, initialing, and dating the correction.
    • Notations for unclear corrections to maintain record integrity.

Filing Systems

  • Filing Methods

    • Paper records can be filed:
    • Alphabetically by owner’s last name.
    • Numerically by patient number.
    • Maintain all patients in the same client file folder and separate animals with colored sheets or cards to indicate various factors (like gender).

  • Alphabetical Filing

    • Each letter gets a distinct color.
    • Does not require a cross-reference to a master list of clients.

  • Numeric Filing

    • Unique client numbers assigned.
    • Each digit in the number assigned a color.
    • Shelved in numeric order from lowest to highest with a required cross-index reference.

Paper Records

  • Utilize Color-Coding
    • For easier filing, use colored numbers or letters.
    • Include colored warning stickers (e.g., Will Bite!, Caution!, Anesthetic Alert!).

Computerized Records

  • Accessibility and Usability

    • Records can be accessed from any computer located in:
    • Reception area
    • Pharmacy
    • Laboratory
    • Radiology
    • Doctor's office
    • Exam rooms and technician areas.

  • Functionality

    • Lab work and other documents can be uploaded or scanned into the medical record.
    • Program lock-out periods to prevent alterations; corrections must be documented as addendums.

Common Practice Management Software

  • Examples
    • AVImark
    • Cornerstone
    • Intravet
    • Impromed
    • DVMAX
    • Other proprietary software and variations exist.

Privacy Act of 1974

  • Regulations
    • No agency may disclose records contained in a system of records without written consent from the individual to whom the record pertains.
    • This regulation applies to all members of the veterinary staff.

Confidentiality

  • Definition and Importance
    • Refers to both written and verbal communication concerning patient information.
    • Medical records can only be released with the owner’s consent, including to groomers or specialists.
    • Common confidentiality breaches occur from discussing cases with unauthorized individuals.

Exceptions to Confidentiality

  • Scenarios Allowing Disclosure
    • Rabies vaccination status.
    • Reportable diseases (e.g., anthrax, rabies, West Nile, hoof and mouth diseases).
    • Injury or death from staged animal fighting.
    • Court-ordered subpoenas.
    • Malpractice complaints.

Medical Records Accessibility

  • Ownership and Access
    • Each patient must have an individual medical record.
    • Multiple animals cannot be recorded on the same sheet but can be kept together in a folder.
    • Records must be complete, legible, and easily retrievable.
    • Clients are entitled to a copy at any time; original records belong to the practice.

Medical Record Formats

  • Chronological Record

    • Traditional format recording visits in chronological or reverse chronological order.
    • May include a master problem list.

  • EMR – Electronic Medical Records

    • No paper files, all records stored digitally.
    • Staff can quickly access and enter data from any workstation.

  • POVMR – Problem-Oriented Veterinary Medical Record

    • Superior to classical records; organized around a master problem list summarizing patient issues.
    • Includes chief complaint, examination findings, lab data, and imaging results, all structured in the SOAP format.

SOAP Framework

  • Subjective (S)

    • Client observations and opinions about the patient’s condition.

  • Objective (O)

    • Factual and measurable information derived from examinations and tests.

  • Assessment (A)

    • Conclusions drawn from the subjective and objective data, including diagnoses and differential diagnoses.

  • Plan (P)

    • Course of action recommended for the patient, such as tests, treatments, or follow-up checks.

Medical Record Contents

  • Included Information
    • Client/patient information sheet.
    • Previous medical history and vaccination records.
    • Primary complaint, physical exam results, diagnosis, lab results, treatments, prognosis, surgical reports, estimates and consent forms.

Chief Complaint

  • Definition
    • Reason for the visit - should describe the patient's situation, not be a diagnosis (e.g., "shaking head" or "swollen paw").

Signalment

  • Components
    • Basic patient information including:
    • Name
    • Age
    • Sex & Reproductive Status
    • Breed
    • Presentation examples:
    • Cooper is a 3-year-old neutered black Labrador Retriever [3yr M/N Black Lab].

History Taking

  • Importance

    • Considered the most critical part of the interaction with the owner.
    • Includes gathering:
    • Current diet
    • Chronic illnesses or medications
    • Vaccination history
    • Symptoms (e.g., coughing, sneezing, vomiting)
    • Parasite control and medication allergies.

  • History Questions

    • Examples include inquiries about eating habits, meal timings, and types of food/treats given.

Progress Notes

  • Usage
    • Records maintained for hospitalized patients and follow-up visits including:
    • Subjective assessments of condition.
    • Objective data like daily findings and diagnostics.

Documenting Drugs

  • Required Details
    • Name of drug, dosage, route of administration:
    • Example of incorrect documentation: "0.2 mL cefazolin IV".
    • Correct example: "20 mg cefazolin IV".
    • Also, document fluid administration clearly with type, fluid rate, and route.

Additional Considerations

  • Documentation Practice
    • Entries must be legible and professional as records may be read by other clinics.
    • Each treatment or medication must be entered on a separate line including all pertinent details.

Client Consent

  • Definition
    • Clients must give informed consent prior to any treatment, evidenced by signature or verbal confirmation (not always written as per California law).
    • May include consent for social media use of pet images/information.

Cage Cards

  • Purpose
    • Identify patients including owner contact details and patient signalment.
    • Displays reason for visit and any special instructions.
    • Follows the patient through kennel movements; may include paper collars for identification.

Purging Records

  • Retention Policies
    • States require records to be kept for 3 years after the last visit; clinics may retain them longer.
    • Inactive records (clients without visits for over a year) may be relocated to reduce clutter.
    • All purged records must be shredded to protect confidentiality.

Discharge & Summary Forms

  • Contents

    • Clear summary of the pet’s illness, prognosis, treatments undergone, and discharge instructions.
    • Ensure clarity for home care so that owners understand follow-up and medication instructions.

  • Follow-Up Practices

    • Recommended to verify understanding with verbal reviews and document discharge information accurately.

Discharge Instructions

  • Information to Include

    • Dietary requirements and restrictions.
    • Activity level (restricted/unrestricted), duration, and any physical therapies.
    • Medication details including type, dosage, administration frequency, contraindications, and timing.

  • Additional Care Guidance

    • Instructions for rechecks, sutures, and overall home care should be included to ensure adequate aftercare for pets.