medical record PowerPoint VT120

MEDICAL RECORDS

PRIMARY AND SECONDARY PURPOSES

• Primary Purpose:

  • Supports Excellent Medical Care
  • Documents Communications

• Secondary Purpose:

  • Supports Business and Legal Activities
  • Supports Research

MEDICAL AND LEGAL REQUIREMENTS

• Must be maintained for all patients where a veterinary-client-patient relationship exists.
• Proper documentation will protect veterinary professionals when a lawsuit or complaint is filed.
• Documentation should be written legibly in either blue or black ink.
• Medical records are the property of the veterinary practice and the owners of the practice.

FORMATS FOR MEDICAL RECORDS

• SOVMR (Source-Oriented Veterinary Medical Record):

  • Format can lack detail and organization as it is kept together by subject matter.
  • Commonly used in herd health.

• POVMR (Problem-Oriented Veterinary Medical Record):

  • Commonly used in regular veterinary practices.
  • Key components include:
  • Signalment
  • Master Problem List
  • Past Pertinent History
  • Chief Complaint
  • The SOAP Note
  • Medication Administration/Order Record forms
  • Surgical reports
  • Summary and Discharge Instructions

SOAP NOTES

• S (Subjective):

  • Experiences, personal views or feelings of the owner, description of the problem at hand.

• O (Objective):

  • Observations made by the veterinarian and technician, including vital signs, physical exam findings, laboratory data, imaging results, and other diagnostic data.

• A (Assessment):

  • The veterinarian's interpretation of what is happening based on the Subjective and Objective data.
  • Includes tentative diagnosis and/or a list of possible rule outs.

• P (Plan):

  • Details the need for additional testing and consultation with other clinicians to address the patient's illness.

OTHER FORMS AND SHEETS

• Treatment Sheets:

  • Ward treatment sheets ensure that patients are observed, receive treatments, and undergo diagnostic tests.

• Cage Cards:

  • Used to identify each patient within cages or stalls.

• Discharge and Summary Forms:

  • Provide clients with a printed summary in simple language.

LOGS

• Surgery Logs:

  • Contains the following information:
  • Date
  • Patient name
  • Procedure
  • DVM/Surgeon
  • Duration
  • Complications

• Anesthesia Logs:

  • Includes:
  • Date
  • Patient name
  • Risk category
  • Protocol
  • Start and End time
  • Procedure and Surgeon name
  • Anesthetist name
  • Complications

• Laboratory Logs:

  • Captures:
  • Date
  • Patient name
  • Diagnostic test run
  • Results

• Radiology Logs:

  • Details:
  • Date
  • Patient name
  • Study type
  • Measurement
  • Technique

• Necropsy Logs:

  • Contains:
  • Date
  • Patient name
  • DVM performing the necropsy

• Controlled Substance Logs:

  • Includes:
  • Date
  • Client name and address
  • Patient name
  • Start volume
  • Amount used
  • Amount discarded
  • End volume

LEGAL REQUIREMENTS

• All logs must be signed and dated.
• The legally required log in veterinary practice is the Controlled Substance log.
• This log keeps the inventory of Schedule II and Schedule III-V controlled drugs.
• Inventory of controlled substances must be completed every two years by the veterinarian.

MANAGEMENT OF PAPER RECORDS

• Alphabetic Filing:

  • Simple and does not require a cross-referencing system.

• Numeric Filing:

  • Assigns a number to each client.

• Active Records:

  • Records that have been used in the past 3 years.

• Inactive Records:

  • Records that have not been used in 4-7 years.