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Records and SOAP

Office Mgmt

QuestionAnswer
What is the technical name for a veterinary medical record? Veterinary Medical Health Information Management
How long does AVMA require inactive records be kept for? 3 years
How long does the state of Texas require inactive records to be kept for? 5 years
Medical records can be detroyed after how many years of inactivity? 8 years
What type of paper records is AAHA approved? letter size folders
What is the most common method for record in regards to "whole herd records"? carbonized sheets
What is the only color ink acceptable for medical records? black
What 3 things should always be included with any entry on a medical record? initial, date and time
What are the 3 methods of filing medical records? Alphabetical by last name, numeric by client number and color coded.
How often should records be reviewed for inactivity? annually
Who do medical records belong to? clinic owner
What are the only 3 reasons medical records can be released without owners permission? bite cases, court orders and reportable diseases
What are the 3 formats of patient records? Source oriented, problem oriented and combination.
What patient record format is AAHA approved? Problem oriented
What type of patient record format is "messy", used in records with limited space and lacks detailed information? source oriented
What type of patient record is utilized in teaching hospitals, is highly structured, and is both logical and organized? problem oriented
Created by: fadedfaithless