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Medical records

medical records

Patient Records Card files; Smaller than letter-size folders Various sized cards Stored in a variety of holder types Limited writing space available Information entered in reverse chronological order Not commonly used
Carbonized sheets Used by large animal ambulatory practices Handwritten notes are made on carbonized papers held in a metal dispenser. One copy is left with the client and the other is taken back to the office. Information is entered into the client’s permanent record.
Forms Surgical Anesthesia Radiography Special imaging Laboratory reports
Patient’s Previous Medical History Animal’s birthplace and date Previous preventive medicine programs Immunizations Parasite control Dental and ear care procedures Behavior (normal and abnormal) Environment Known allergies or reactions Previous medical or surgical conditions
Patient’s Previous Medical History Animal’s birthplace and date Previous preventive medicine programs Immunizations Parasite control Dental and ear care procedures Behavior (normal and abnormal) Environment Known allergies or reactions Previous medical or surgical conditions
Patient Recent Medical History Presenting complaint or episode The last time the animal was “normal” Frequency of episodes Current medications Previous treatment efforts for this complaint Owner concerns and comments Current diet Information from referring or previous veterinari
SOAP Subjective, Objective, Assessment, Plan Used to assess and plan or adjust treatments for hospitalized patients Performed at the beginning of each day
SOAP-s- Subjective Performed by the veterinary technician How the animal appears from casual observation
Objective Performed by the veterinary technician Physiologic data such as temperature, pulse, respiration, vomitus, urination, defecation Laboratory data such as blood analysis Notes on surgical site, catheter placement, swelling, drainage
Assessment Performed by veterinarian Determines the overall status of the patient Tentative diagnosis is developed
Plan Presented by the veterinarian The course of action for the day
Logs Provide additional documentation for legal support Provide data for quick analysis Provide data for retrospective studies Provide data from throughout the practice Radiology log Surgery and anesthesia logs Necropsy log Controlled substances log
The Comprehensive Drug Abuse and Control Act Regulates the possession of drugs that have a potential for abuse
The Comprehensive Drug Abuse and Control Act Drugs are placed in one of five schedules depending on their addictiveness: Schedule I drugs are the most addictive Schedule V drugs are the least addictive
The Comprehensive Drug Abuse and Control Act Every instance of drug use must be recorded in a permanent log
Filing Systems Alphabetic, Numeric
Alphabetic Each letter is assigned a different color Does not require cross-reference to a master list of clients Incorrectly spelled names can be misfiled Employees must know how to correctly apply alphabetic order
Numeric Each client is assigned a unique number Each digit in the number is assigned a different color
Numeric Files are shelved from lowest to highest in numeric order Misfiled files are easy to spot Must cross-reference a master list to retrieve a client’s assigned number
Legal Issues Ownership of medical records The practice owns the records even though the client purchased the services.
Release of medical information Clients should submit a written request for record copies before any information is released to anybody. The practice owner authorizes information release. Reportable diseases and rabies immunization status are exceptions
Legal Issues Maintenance of medical records
Maintenance of medical records Guidelines vary from state to state Type of information kept How long records must be kept Restrictions on the release of medical information
Created by: JODY84



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