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Records and SOAP
Office Mgmt
Question | Answer |
---|---|
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 |