Veterinary Medical Records

Veterinary Medical Records

Purposes of the Medical Record

Primary Purposes

• Supports excellent medical care by providing a comprehensive view of the patient's health history, treatment interventions, and outcomes.

• Documents procedures and communication between the veterinarian, staff, and client, ensuring clear accountability and understanding of care.

Secondary Purposes

• Supports business activities such as billing, inventory management, and financial analysis.

• Supports legal activities by providing evidence of care and treatment in case of disputes or malpractice claims.

• Supports research by contributing to data collection for veterinary studies aimed at improving animal health care practices.

Medical and Legal Requirements

Veterinarian–Client–Patient Relationship (VCPR) exists when:

• The veterinarian takes full responsibility for their clinical judgments regarding the animal's health, and the client agrees to follow through with the veterinarian’s recommendations.

• The veterinarian is familiar with the animal's care and has established a recent oversight of its health.

• Emergency care and follow-ups are organized to ensure continued assessment of health outcomes.

• Patient records are meticulously maintained to reflect treatment history and health changes.

Ownership and Release of Medical Information

• Medical records are legally owned by the veterinary practice rather than the individual client, ensuring that the practice maintains oversight of all patient information.

• Clients have the right to request copies of their pet’s records; such requests can be fulfilled through mail or secure email while always including a cover letter for authorization.

• Signed authorization from the client is necessary for releasing any information.

• The American Veterinary Medical Association (AVMA) outlines specific state privacy guidelines that practices must adhere to, highlighting the importance of confidentiality in veterinary care.

Format of Veterinary Medical Records

Source-Oriented Veterinary Medical Records (SOVMR)

• The SOVMR format organizes patient information chronologically by office visits or hospital stays, with the oldest information documented first in paper records and potentially the most recent in certain electronic systems.

• This system provides ease of usage for veterinarians accessing patient histories in a linear fashion.

Problem-Oriented Veterinary Medical Records (POVMR)

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• Utilizes the SOAP format to ensure a thorough approach to diagnosis and treatment:

  • Subjective: Information reported by the client regarding symptoms and behavior.

  • Objective: Observable data collected by the veterinarian, such as physical exam results and laboratory data.

  • Veterinarian's role includes identifying the cause of illness and determining an appropriate treatment plan.

  • Veterinary Nurse's role involves observing the patient's psychological and physiological reactions to treatments, enhancing communication among the veterinary team, and assisting in ongoing assessments.

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• Components of the POVMR include:

  • Client and patient information such as contact details and demographics.

  • A detailed history and physical examination findings that contribute to understanding the patient’s current state.

  • Pertinent test results and diagnostic imaging findings that assist in forming an accurate diagnosis.

  • A Master Problem List to track significant medical disorders throughout the patient’s life, perhaps including a preventive medical history summary for comprehensive care.

  • A Working Problem List to actively track current health problems.

  • Progress notes, assessments, and an action plan that outlines further care, treatments, and follow-up goals.

Hospitalized Patient Records

• Each problem identified in initial plans and daily management is recorded using the SOAP format to track the progress and outcomes of care provided during hospitalization.

• Subjective and Objective data are meticulously documented, focusing on both measurable and non-measurable observations.

• Assessment guidelines established by veterinary technicians and veterinarians help facilitate a structured treatment plan.

SOAP Notes

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• Subjective: Includes the presenting complaint, client observations, and any physical exam findings reported by the client or identified during the examination.

• Objective: Comprises physiologic data, laboratory results, surgical notes, and pain scoring, ensuring a factual basis for diagnosis and treatment decisions.

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• Assessment: Involves analysis of both subjective and objective data, prioritizing the patient's needs and developing tentative diagnoses based on that information.

• Plan: Outlines interventions derived from the assessment, along with actions undertaken for patient care, ensuring that treatment goals are clear and achievable.

Electronic Medical Records (EMRs)

• EMRs provide a wide variety of software products designed to improve records management in veterinary practices.

• Advantages include:

  • Improved legibility, consistency, and completeness of medical records, reducing the likelihood of errors.

  • Utilization of templates and prompts that facilitate efficient record-keeping processes.

  • Reduced risk of record loss, with integration capabilities for diagnostics such as ECG and radiographs.

Security of EMRs

• EMRs must follow American Animal Hospital Association (AAHA) standards, including:

  • Automatic closing of patient records after a specified duration of inactivity to protect sensitive information.

  • Off-site storage requirements and third-party validation to ensure data safety and integrity.

  • Implementation of risk management strategies, such as backup servers and generators to prevent data loss during emergencies.

Paper Medical Records

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• Advantages:

  • Do not require a power source for access, making them reliable in various settings.

  • No need for frequent system updates or maintenance, ensuring continuous access.

  • Noteworthy durability, resilient to software failures or technical issues.

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• Disadvantages:

  • Susceptible to being misplaced or lost due to their physical nature.

  • Accessibility is limited to one person at a time, creating bottlenecks in record retrieval.

  • Can lead to inconsistent documentation and/or illegibility in note-taking.

• AAHA requires maintaining unique medical records for each patient, organized in letter-sized folders to streamline access.

• Employ colored forms or tabs for easy organization and filing, utilizing either an alphabetic or numeric system for efficient retrieval.

• Implement considerations for purging records based on the patient's activity level and history.

File Purging

• A review process is recommended at least once a year to ensure records are up to date.

• Primary records: Active records maintained for the last three years.

• Storage records: Records deemed inactive and maintained for over four years.

• Purge records: Records inactive for over eight years should be thoroughly reviewed and potentially destroyed to maintain confidentiality and manage space.

• It is vital to notify clients about the loss of records and to strive for reestablishment as promptly and efficiently as possible to maintain trust and legal compliance.

Questions?

• Any questions or discussions about veterinary medical records can be addressed here to ensure clarity and understanding.