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VTHT Ch 14
Question | Answer |
---|---|
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 |