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