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12 Cards in this Set
- Front
- Back
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. |
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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 |
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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 |
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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 |
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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. |
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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 |
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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. |
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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 |
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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 |
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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) |
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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 |
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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 |