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Ch 2 Medical Records

SR Vocab

TermDefinition
Objective Information Measured facts, such as vital signs (TPR)
Medical Record Written and recorded information on the care and treatment of the animal
Consent Form Permission given by owner to treat animal (surgery, euthanasia)
Assessment veterinary (DVM) diagnosis of problem
Neuter Certificate documentation the animal has been spayed or castrated and is no longer able to reproduce
Plan Treatments or procedures provided
Progress Notes documentation chronologically detailing the patient's history, treatments, and outcomes
Subjective Information observations of the animal's appearance and behavior made by the veterinary staff or owners
Health certificate documentation that an animal is in good health and can be transported out of state or the country
SOAP subjective information, objective information, assessment, and plan; method used for documentation in a medical record
Created by: Mrs. Lemke
 

 



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