medical records
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| 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
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| 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.
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| Forms | Surgical
Anesthesia
Radiography
Special imaging
Laboratory reports
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| 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
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| 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
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| 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
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| SOAP | Subjective, Objective, Assessment, Plan
Used to assess and plan or adjust treatments for hospitalized patients
Performed at the beginning of each day
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| SOAP-s- | Subjective
Performed by the veterinary technician
How the animal appears from casual observation
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| 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
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| Assessment | Performed by veterinarian
Determines the overall status of the patient
Tentative diagnosis is developed
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| Plan | Presented by the veterinarian
The course of action for the day
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| 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
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| The Comprehensive Drug Abuse and Control Act | Regulates the possession of drugs that have a potential for abuse
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| 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
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| The Comprehensive Drug Abuse and Control Act | Every instance of drug use must be recorded in a permanent log
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| Filing Systems | Alphabetic, Numeric
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| 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
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| Numeric | Each client is assigned a unique number
Each digit in the number is assigned a different color
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| 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
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| Legal Issues | Ownership of medical records
The practice owns the records even though the client purchased the services.
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| 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
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| Legal Issues | Maintenance of medical records
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| 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
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