Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
20 Cards in this Set
- Front
- Back
|
Functions: Primary Purposes
|
1. Supports excellent medical care
2. Documents communications |
|
|
Functions: Secondary Purposes
|
1. Supports business/legal activities
2. Supports research |
|
|
Excellent Medical Care
|
- Identifies client/patient
- Prevents confusion - Helps generate effective diagnostic/treatment plan - Enables documentation of how patient responds - Communication between veterinary team members |
|
|
Documents Communications
|
- Communication with client documented
a. Take-home instructions b. Medications c. Animal behavior |
|
|
Business/Legal Activities
|
- Lists all services rendered
a. Provides legal evidence b. Verifies dates/times of services or treatments performed - Verifies billing - Insurance companies |
|
|
Supports Research
|
- Preperation of case studies and presentations for conferences
- Databases for students |
|
|
How Long to Keep Medical Records
|
- 5 years after the date of the last visit
- Can become inactive after 3 years |
|
|
Types of Patient Records
|
- Electronic
- Hard copies a. Letter size folders b. Card files |
|
|
Format of the Patient Record
|
1. Source-oriented
2. Problem-oriented |
|
|
Source-Oriented
|
- Limited space
- Information entered chronologically - Time saver - Lack of detail |
|
|
Problem-Oriented (POVMR)
|
- Provides entire view of patient
- Supports logical/organized approach to clinical medicine - Fosters excellent communication - Rapid retrieval of information |
|
|
Common Components
|
- Client information
- Patient information - Pertinent history - Previous history - Physical exam information - Pertinent forms - Financial records |
|
|
Client Information
|
- Name
- Address - Phone number - Alternate phone number - Referring person |
|
|
Patient Information
|
- Name
- Signalment - Color - Markings - ID number - Microchip number |
|
|
Pertinent History
|
- Presenting complaint
- Last normal - Frequency of episodes - Client observations and concerns - Allergies - Current diet |
|
|
Previous History
|
- Previous problems
- Previous treatments and outcomes - Previous surgeries - Previous medications - Previous diagnostic tests - Immunizations - Environmental history - Travel history - Weight history - Previous diet |
|
|
Physical Exam Form
|
- Master problem list
- Working problem list - Progress notes |
|
|
Master Problem List
|
Major medical problems experienced during its lifetime
|
|
|
Working Problem List
|
Assist clinician in working through problems
|
|
|
SOAP
|
S - Subjective
O - Objective A - Assessment P - Plan |
