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VOP Lecture 3
Spring 2023 Lecture 3
| Question | Answer |
|---|---|
| Purpose of Record Keeping: | detailed description of medical issues (progress, resolution, etc..), treat like human records, legal document, medical history, looks at summary of animal's health, rapid retrieval of animal/client information, documentation |
| Medical Records: | legal document with detailed information on the patient and client (3 yrs), WRITE IN INK; documentation of animal's health and care history |
| Creating Medical Records: | client information (name, address, phone number, etc.), patient information (breed, age, species, etc.), preventative care regimen (Vx, surgeries, diagnostic tests, physical exams, etc.) |
| Making a change on a record: | ONE line through mistake, write in new info, initial, ALWAYS USE INK |
| Information on Records: | Objective (measurable data (HR, RR, etc.)) and subjective (personal opinion (body condition, gait, etc.)) |
| Source-Oriented Medical Record: | most widely used, conventional format, records of multiple patients kept in 1 folder |
| Problem-Oriented Medical Record: | very detailed, complete detailed record on every pt. in hospital, more intensive note-keeping |
| Master Problems List: | anything requiring a veterinarian's attention |
| Most recent information in a file goes: | on top |
| SOAP: | Subjective information, Objective information, Assessment (done by vet), Procedure/Plan (done by vet) |
| Storage of Medical Records: | need to be easy to access and have flexibility as volume increases; filing cabinets can be vertical or horizontal |
| Maintenance of Records: | need to be accurate, record lab results in a timely fashion, ask about animals not seen in awhile, make note of phone conversations, most recent sheets on top |
| Alphabetic Filing System: | most common, label with sticker, or each letter gets assigned a different color |
| Numeric Filing System: | provides a degree of confidentiality, each client is assigned a number OR each patient gets a number |
| Color Coding Filing System: | certain colors code for inactive, deceased, cash-only clients |
| Purging of Medical Records: | eliminate charts of inactive patients; decreases clutter and allows more space in filing cabinets; should be done 1-2 times per year |
| Use of Computer: | easy storage, communication, maintenance accuracy, purging of records, clinic website/social media, vet software (appointments, etc.) |
| Websites should have: | driving directions, map, contact information, FAQs, links, forms, scheduling, prescription refill, specialty services, general pet health/information, staff |
| Consent Form: | all animals at clinic should have one signed, kept in chart, client reads and signs the form to give consent for the procedures to be done and acknowledge the potential risks |
| Admission Form: | written consent to proceed w/ diagnostic testing, surgery, treatment plan |
| Surgical Consent Form: | pre-op safety precautions, benefits, risks, potential outcomes, operative IV fluids, post-op care and pain management |
| Spay-Neuter Certificate: | when the animal is no longer able to reproduce; necessary when licensing your dog |
| Vaccine Certificate: | can be computerized, generate future reminder mailings/callback, can help ID a lost animal |
| Health Certificate: | necessary for interstate transportation, international transportation; can be completed on computer and given to vet for signature |
| Discharge Instructions: | written home care instructions after surgery; medications, dietary modifications, activity level, bathing, checking incision site, etc., follow-up visits |
| Referral Letter: | comprehensive information pertaining to patient's history, another vet can make choices about pet right away, state presenting complaint, tests performed, describe treatment, patient progress, explain why referral is being made |
| Brochures and Newsletters: | brochures are great for new clients (have phone number, address, services available, etc.); newsletters are a great way to update existing clients |
| Inventory Process: | have a 'want list' in an easily accessible place, add to it if you only see a few left of something; usually one person in charge of ordering, etc.; KEEP INVENTORY SEPARATE FOR OFFICE, PHARM, ETC. |
| Physical Inventory: | needed along with computerized inventory, involved physically counting every single item |
| Logbooks are necessary for: | controlled substances, x-ray, anesthesia/surgery, laboratory |
Created by:
mkroon26
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