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10 Cards in this Set

  • Front
  • Back
Who should enter information into a patient's medical records?
-veterinarian
-RVT
-Receptionist
The medical record is the property of?
The veterinary clinic
In California are you required to provide clients with photocopies fo their pets medical records on request?
No just a summary of the records
How long should a medical record be kept for before placing in an inactive file?
3 years
In the acronym SOAP what does each letter stand for? Identify where Dx, P.E., Tx and Hx would be placed.
S - Subjective - Hx
O - Objective - P.E.
A - Assessment - Dx
P - Plan - Tx
What type of log used in a veterinary clinic is a legal requirement?
Controlled substance log
What does POVMR stand for?
Problem Oriented Veterinary Medical Record
What does a POVMR do?
divides record into 4 parts - database, problem list, plans section and progress section
Describe how to deal with an error written into a medical record?
cross it out and initial next to it
What are the 3 types of medical record systems?
1-card file
2-folder file
3-computer file