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12 Cards in this Set

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Documentation

Write everything down as you go along or as soon as possible - if it is not documented, YOU DIDN'T DO IT!


Your physical exam is a legal record that can protect you from litigation - if you need to make changes, cross out original writing with one line and initial it.



Purpose of record keeping

Historical patient archive


Communication


Aid in Diagnosis


Legal record


Clinical research (e.g. look at all the cats in the last 6 months who have come in with enlarged lymph nodes)


Aid to billing

Legal requirements of record keeping

Owner and animal identification


Species, breed, age, sex, color


Admission and discharge dates


Physical exam findings


Diagnosis - can be clinical or definitive


Treatments, surgery, and anesthesia reports


Progress reports


Radiographs with permanent identification Waivers and denial of recommended prescriptions

How long do I have to keep records?


What obligations do I have to requests for records?


Can I withhold records from non-paying clients?

3 years minimum


Copy or synopsis within 5 days


No

S.O.A.P (I.E.R)

This record structure is the basis of a problem oriented medical record. It reflects the way most practitioners think about and talk about a case when communicating with others.


S - subjective (or story)


O - objective


A - assesment


P - plan




I - intervention


E- evaluation


R - revision


used mostly in human medicine - we usually just use an addendum.

S (subjective)

What the owner complaint is - what happened, why are we here


How you "think" the animal is doing in the hospital


S is also for story


example: patient came in with a history of poor appetite and two episodes of vomiting

O (objective)

If you can measure it, it belongs here


Blood work, TPR, physical/neuro/optho/ortho


exam results, procedure reports


radiology? some objective, some subjective


Example: Body temp was 102.1, heart rate was 140, RR was a pant.

A (assessment)

In some ways, it is the most critical part of the record


Where you present your thought processes and logical approach


Define problems only at the level you understand them - don't jump to a diagnosis


Example: evidence of acute kidney injury with several possible etiologies


Often include a working diagnosis or suspicion


For an easy outpatient type of case there should be a clinical diagnosis and supporting evidence in your records

P (plan)

Where do we go from here?


Can be list of additional diagnostics, a plan for treatment, a plan for referral, a plan to "wait and see"


Discharge letter - give explicit directions for rechecks, milestones etc.


Referral letter - give indications of what has been communicated to the owner regarding onward plans. Is the animal coming back, what do we wan the RDVM to do?


The plan is guided by which problems you will assess further and how you will do that



Differentiating problems

Define problems from the S and the O


Differentials are part of the assessment and lead to the plan


Define the problem only at the level you understand it. Example: harsh, productive cough (not pneumonia)



Identifying high yield problems

high yield problem - one that has a relatively limited number of differentials which are easily distinguished via diagnostic testing (like an electrolyte imbalance)


Or a problem with a high probability of killing the patient

Differential List

Come up with a list of disorders that could be causing the problem


DAMN IT system


D - developmental


A - anomalies, autoimmune


M - metabolic


N - nutritional, neoplastic


I - inflammatory, infectious, immune mediated, idiopathic, iatrogenic


T - toxic, traumatic