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VTHT Ch 14

QuestionAnswer
Why is legibility so important in medical records? if you can't read it, it didn't happen
How often are medical records purged? varies from state to state - TX is 5 years
What is the earliest that records can be shredded? 5 years from last visit
Why is history taking critical for a medical record? it helps the vet make a proper diagnosis
What is a SOAP progress note? Subjective, Objective, Assesment, Plan which is included in the progress section of a problem oriented medical record. S- reason for visit O - physical exam A - diagnosis P- treatment
What items are mandatory in a medical record?
Why are discharge sheets vital? clients remember 30% of the information provided while at the practice.
Does a client record belong to the client? No
Who owns the radiograph of a pet? clinic
what is the most common method for filing paper medical records? alphabetical by client
true or false: legible, complete medical records are an asset to the hospital, and they bring value during a valuation TRUE
medical records can be release to whom? The owner and someone with the owners consent
The objective portion of the SOAP format includes: a. chief complaint b. observations of team members upon check-in c. physical exam d. diagnosis c. Physical exam
purging medical records: a. increases lost records b. is required by law c. allows inactive records to be shredded d. moves inactive medical records to another storage area c. allows inactive records to be shredded
medical record audits should: a. capture missed charges b. identify incomplete medical records c. identify lapses in recommendations d. all of the above d. all of the above
Created by: kcrabtree507