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23 Cards in this Set
- Front
- Back
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Primary Function |
ID Diagnostic Treatment Plans Communication |
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Secondary Function |
Legal Document Inventory Marketing Billing Research |
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Signalment |
Breed Age Reproductive Status Sex |
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Client Info |
Full name Address Contact info |
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Vet-Client-Patient-Relationship |
Vet assumes responsibility Vet has sufficient knowledge of patient Vet has arranged for emergency care if unavailable |
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Legal |
Clinic owns record Client has rights to copy of record |
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Record Release |
Cannot release without permission except for court cases and reportable diseases |
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AVMA Standards |
Comply with state and federal law Record retained for period required by law Must not be released except for when required by law Cannot use records for personally gain |
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Do's and Don'ts |
If not written it didn't happen Must be initialed Mistakes crossed out and written in Recognized abbreviations only |
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Source-Oriented |
Chronological Latest visit on top |
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Problem-Oriented |
Major issues listed and numbered on a cover sheet with date entered and date resolved Each issue has working progress list and notes |
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SOAP |
Subjective, Objective, Assessment, Plan |
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File Puring |
Review yearly Primary- active in the past 3 years Storage-inactive for 4 years Shred- after 7 years |
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Logs |
Controlled Substances Anesthesia Radiology Euthanasia Surgery Lab Procedures |
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Electronic Records Advantages |
Fast Access Easily sent to other clinics |
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Electronic Records Disadvantage |
Can easily enter a date in the wrong record Risk of loss Risk of hacking |
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Letter-sized |
Most common Each patient has their own folder |
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Card Files |
"outdated" AAHA will not accredit if used |
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Carbonized Sheets |
Ambulatory Allows client to a have copy |
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Log Functions |
Provide additional documentation for legal support Provide data for quick analysis |
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What Happens If You Lose a Record |
Start a new one and note that the previous record was lost |
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What Medical Record System Does This Program Use? |
Avimark |
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What Type Of Medical Record Requires SOAP Notes? |
Problem-Oriented |
