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10 Cards in this Set

  • Front
  • Back
Who should enter information into a patient's medical records?
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