Medical Records

Medical Records 

By Michelle Albino, CVT 

UW Veterinary Care

  • Referral Coordinator, Dec 2020 - June 2022

  • Client Services SUpervisor, June 2022 - Present 

Patient Scheduling Representative, UW Health 

  • March 2017 - October 2020

  • Dermatology, Rheumatology, and Endocrinology 

CVT, Northside Animal Hospital 

  • June 2010 - March 2017 

Associates of Applied Science in Veterinary Technology, MATC

  • Class of 2010


Why are medical records important?

  • The primary purpose of the medical record is to provide an accurate and comprehensive description of the patient’s medical history, treatments, and outcomes of those treatment over the entire life of the patient 

  • A comprehensive history will prevent things like repeating laboratory testing or other unnecessary procedures, for example, giving the patient ad rug they may be allergic to 

  • In an academic setting, patient medical records can also help with research or teaching 

  • Medical records are a legal document government by state laws and statutes

Usually required to keep medical records for 7 yrs


What makes up a patient's medical record?

  • Demographics 

  • Client information: legal name, including middle initial, address, DOB, email address, reminder preferences, alternate contacts, alternate contact phone numbers 

    • Usually collect DOB due to pet prescriptions and risk 

  • Patient information: Name, species, breed, DOB, sex and reproductive status, color

    • Signalment: a complete description of the patient including species, breed, age and date of birth, sex and reproductive status (whether the animal is neutered or intact)

  • History - including diet, environmental factors, like if there are other pets in the household weight, vaccination status, etc. 

  • Examinations - normal vs. abnormal values 

  • Treatments - examples?

  • Outcomes of treatments

  • Diagnostics - examples

  • Photos, video, imaging (CT, MRI, etc.)

  • Billing/procedures, prescriptions, estimates, etc.


@ UW MADISON VET CARE

  • Some medical record items are on paper, some electronic, some are stored on other media like DVD, or stored in the cloud 

  • We try our best to have all of the info available but it is challenging 

  • We are working toward being fully  paperless in the near future


Examples of items kept on paper 

  • Authorization forms that need a physical signature 

  • History - patient history might be taken in an area where a computer isn’t available. Sometimes necessary to jot down notes

  • Sometimes the computer system you use doesn’t have the capability recording info the way you want to. 

  • Photos provided by the client 

  • Others?

Examples of items stores electronically 

  • Case summaries are typed up and printed for the client They are also sent via email or faxed directly femur the HIS (hospital information system), Stringsoft

  • Any communication with the client is logged electronically 

  • Laboratory results

  • Prescription, refills

  • Diagnostic imaging reports 

  • Others? Scanned in documents, billing, other medical record reports 

Advantages of electronic medical records 

  • Only have to record historical information once 

  • Paper records can get lost 

  • Always legible 

  • Access information remotely 

  • Info can be shared by multiple parties

  • Web portals similar to MyChart lets the client instantly access medical records for their pet(s)

  • Can identify trends like following lab results over time - i.e. blood glucose levels in a diabetic patient 

  • Physical space for storage of records not necessary 

  • Multiple people from different areas of the hospital can be accessing the record at the same time - i.e. student can be typing a discharge reports while radiologist is entering their finding 

  • An audit trail is maintained and you can view who did what in the EMR 

Important aspects of medical records

Whether stored on paper or electronically, always make sure medical records are: 

  • Accurate

  • Completed in a timely fashion - it is important to write the medical record reports either during the patient visit or shortly after the visit. This is because you can forget details of the case as time goes by. 

  • Chronological 

    • Paper medical records put in order by medical records staff and then filed in the physical medical record 

    • Complete - document everything that was done, also if O declines something 

      • If it isn’t documented it didn’t happen 

Medical record standards 

Although we are not governed by all of the strict laws and guidelines that exist in human medicine, we always strive to meet privacy and security standards to protect the confidentiality and integrity of the medical record as well as the privacy of our clients.

Examples of how we strive to meet the standards are:

  • Retain records for 20 yrs after most recent visit 

  • Maintain patient confidentiality - we only release records to the client unless the client has given us permission to release records to another individual 

  • Store electronic medical record data on secure servers

  • Formal backup plan of electronic medical record data with off-site storage

  • Shredding of any paper containing configuration client info eg credit card number 

  • Encrypt data on server when necessary 

  • System security so that only clinicians (not students) can finalize medical record reports. This is a safeguard, ensure accuracy 

How does your practice strive ot meet medical record privacy and security rules/guidelines?

UWVC Client Services Department 

  • 6FTE + Michelle 

    • Supervisor 

    • 1 FTE Chart prep for next day’s visit and add-ons/emergencies 

      • 80-121 appts per day 

      • In FY 2021 - 29,451 visit s

      • In FY 2022 - 28,685

    • 1 FTE Chart check-in and form completion 

    • 1 FTE Referral Coordinator 

    • 3 FTE Client Services Specialists 

    • 1 Student worker 

  • Charts for patients seen at UWVC in the past 4 years are stored in client services 

  • Charts are checked out and checked back in when they are returned (just like a library)