Sam I Pe/record Keeping

Front 1

integument

Back 1

skin

Front 2

CRT

Back 2

capillary refill test
1-2 seconds

Front 3

alopecia

Back 3

hair loss

Front 4

BAR

Back 4

bright alert responsive
measures alertness

Front 5

cherry eye

Back 5

enlargement of 3rd eyelid gland

Front 6

ectropion

Back 6

outward rolling of eyelid
cockers, bulldogs, bloodhounds

Front 7

Entropion

Back 7

eyelashes rolling in
chow, shar pei, st. bernard, golden

Front 8

pinna

Back 8

ear flap

Front 9

mm

Back 9

mucous membrane
1-2 sec

Front 10

pulse deficient

Back 10

pulse is less than heartbeat

Front 11

conjunctiva

Back 11

membrane covering inner surface of eyelids
should be light pink,thin

Front 12

sclera

Back 12

coating of eyeball
white, thin blood vessels

Front 13

cornea

Back 13

clear covering front of eye
cloudiness, lesions

Front 14

lens

Back 14

behind pupil
shine light cloudiness or reflection

Front 15

Dog dental Formula

Back 15

2 (I 3/3, C 1/1, P 4/4, M 2/3 )=42

Front 16

Cat dental formula

Back 16

2 (I 3/3, C 1/1, P 3/2, M 1/1)=30

Front 17

Deciduous teeth erupt in dogs

Back 17

4-6 weeks

Front 18

deciduous teeth erupt in cats

Back 18

3-6 weeks

Front 19

permanent teeth erupt in dogs

Back 19

4-7 mo

Front 20

permanent teeth erupt in cats

Back 20

3-5 mo

Front 21

tachycardia

Back 21

heartrate is more rapid than normal

Front 22

bradycardia

Back 22

heart rate slower than normal

Front 23

sinus arrhythmia

Back 23

normal in dogs
heart rate speeds up when breathes in and slows down when breaths out

Front 24

arrythmia

Back 24

any unusual pattern of heart

Front 25

dyspnea

Back 25

difficulty breathing
#1 emergency

Front 26

rales

Back 26

abnormal lung sounds
dry-harsh, rubbing
moist-bubbling, cracling

Front 27

mastitis

Back 27

infected mammary gland
will be hot and painful

Front 28

cryptorchid
2 terms

Back 28

a testicle/both not decending into scrotum
1-monorchid
2-bilateral cryptorchid

Front 29

what to look for when examining prepuce

Back 29

any grit--indicates urinary calculi

Front 30

perianal

Back 30

area surrounding anus

Front 31

anal sacs location

Back 31

4 and 8

Front 32

crepitus

Back 32

grinding feeling or sound

Front 33

laxity

Back 33

looseness (of joints)

Front 34

righting reflex

Back 34

tests coordination-placed in dorsal recumbency and left to roll back up

Front 35

Proprioception

Back 35

placing paw upside down to see if it will right itself

Front 36

5 lymph nodes

Back 36

mandibular
prescapular
axillary
inguinal
popliteal

Front 37

ear drum

Back 37

tympanum

Front 38

hyperkeratosis

Back 38

cracked, thickened nose and toepads

Front 39

Normal Temp Dog

Back 39

100-102.5

Front 40

Normal temp Cat

Back 40

100-102.5

Front 41

normal pulse dog

Back 41

70-130bpm

Front 42

normal pulse cat

Back 42

110-180bpm

Front 43

normal resp. dog

Back 43

10-30rpm

Front 44

normal resp. cat

Back 44

10-30rpm

Front 45

pv

Back 45

powder

Front 46

gm

Back 46

gram

Front 47

gr

Back 47

grain

Front 48

ss

Back 48

half

Front 49

fl

Back 49

fluid

Front 50

ung

Back 50

ointment

Front 51

gtt

Back 51

drop

Front 52

aq

Back 52

water

Front 53

sol

Back 53

solution

Front 54

supp

Back 54

suppository

Front 55

IM

Back 55

intramuscular

Front 56

IV

Back 56

intravenous

Front 57

ID

Back 57

intradermal

Front 58

IP

Back 58

intraperitoneal

Front 59

SQ

Back 59

subcutaneous

Front 60

PO

Back 60

by mouth, orally

Front 61

per os

Back 61

by mouth, orally

Front 62

OS

Back 62

left eye

Front 63

OD

Back 63

right eye

Front 64

OU

Back 64

both eyes

Front 65

AS

Back 65

left ear

Front 66

AD

Back 66

right ear

Front 67

AU

Back 67

both ears

Front 68

a

Back 68

before

Front 69

p

Back 69

after

Front 70

c

Back 70

with

Front 71

s

Back 71

without

Front 72

ad lib

Back 72

at liberty

Front 73

prn

Back 73

as neccessary

Front 74

QD

Back 74

once daily

Front 75

SID

Back 75

once daily

Front 76

BID

Back 76

twice daily

Front 77

TID

Back 77

three times daily

Front 78

QID

Back 78

four times daily

Front 79

QOD

Back 79

every other day

Front 80

EOD

Back 80

every other day

Front 81

q

Back 81

every

Front 82

qh

Back 82

every hour

Front 83

nr

Back 83

do not repeat/renew

Front 84

stat

Back 84

immediately

Front 85

Check head for
(4)

Back 85

eyes, ears, mouth and throat

Front 86

check neck and back
(4)

Back 86

soft tissues, neck movement, palate spine, gross deformities

Front 87

Check eyes for
(6)

Back 87

eyelids, discharge, conjunctiva, sclera, cornea, lens

Front 88

Check ears for
(3)

Back 88

pinna, canal, otoscopic exam

Front 89

mouth and throat
(4)

Back 89

jaw alignment, mucous membranes, teeth, age of teeth

Front 90

Thorax, heart, lungs
(5)

Back 90

palpate ribs, ausculate lungs, heart rate + pulse, heart rythm + sounds, respiration

Front 91

Abdomen
(3)

Back 91

outer, inner, mamarry glands

Front 92

Genitals
(4)

Back 92

vulva, spay incision, testicles, penis

Front 93

Perianal Area
(3)

Back 93

fecal mats, parasites, anal sacs

Front 94

Extremities
(5)

Back 94

Feet, bones, joints, muscle mass, loss of mobility

Front 95

Neurological
(2)

Back 95

coordination, sensory
(sight + hearing)

Front 96

RK rule #1

Back 96

Use Ink-blue or black

Front 97

RK rule #2

Back 97

Write legibly

Front 98

RK rule#3

Back 98

Be precise

Front 99

RK rule #4

Back 99

Spell correctly

Front 100

RK rule #5

Back 100

abbreviate when possible

Front 101

Rk rule #6

Back 101

Be neat-never use white out
draw a single line through errors and initial

Front 102

RK rule #7

Back 102

before starting a new record--see if patient already has one

Front 103

RK rule #8

Back 103

Use care when filing

Front 104

RK rule #9

Back 104

Initial all entries in body of record

Front 105

RK rule #10

Back 105

most recent page is on top

Front 106

Purpose of record keeping

Back 106

Provides past and present information for diagnosing
onlymeans of reference for animal's medical history
Legal document!

Front 107

3 parts of a record

Back 107

owner info
animal info
animal history

Front 108

What is in owner info

Back 108

salutation, title (Mrs., Mr etc)
client name
address
phone #'s
referred by if possible

Front 109

What is in animal info

Back 109

pet's name (spell correctly)
sex (spayed/neutered)
breed/color and markings
age/date of birth

Front 110

What is in animal history

Back 110

vaccination history
previous lab test results
allergies
past major medical problems/surgeries

Front 111

Methods of collecting client/animal info

Back 111

1. client/patient info sheet-standardized form
2. record transfer
3. Interview

Front 112

Method for recording medical info

Back 112

1. date and time
2. reason for visit
3. review of systems
4. physical exam
5. lab tests
6. analyze data
7. other necessary info

Front 113

what is included in date and time?

Back 113

arrival time
wait time

Front 114

what is included in reason for visit?

Back 114

C.C.
present illness
*duration
*onset-acute or chronic
*improvement?

Front 115

what is included in PE?

Back 115

TPR + weight
initial PE

Front 116

what is included in lab tests

Back 116

based on clinical signs and pe findings
tech records results

Front 117

what is included in analyzing data?

Back 117

a. problem list
b. initial plan
c. progess notes:
S: subjective-how animal appears
O: lab or procedural results
A: assessment dianosis/prognosis
P: treatment or additional tests

Front 118

What is included in other neccessary info?

Back 118

allergic reactions
patient's disposition
phone contacts-what was said

Front 119

S.O.A.P.

Back 119

S: Subjective
how animal seems to be doing, observations
O: Objective: lab or procedural results
A: Assessment: diagnosis or prognosis
P: Plan: treatment or additional tests needed, follow up care

Front 120

Additional record keeping duties
(8)

Back 120

1. reminder cards
2. rabies certificate and tag book
3. pet health records
4. health certificates
5. lab results
6. money transactions
7. log books
8. authorization forms

Front 121

Filing systems
(3)

Back 121

Alphabetical
Numerical
Color coded

Front 122

alphabetical filing system

Back 122

last name first

Front 123

numberical

Back 123

client account number
cross-index matches client name to account

Front 124

color coded

Back 124

speeds up filing process, easy to find misfiles

Front 125

Filing precautions
(5)

Back 125

be careful-misfules
clients see them-appropriate and sensitive
keep inactive files separate
take deceased animals off reminder card system
file abbreviations as if they are spelled out

Front 126

Telephone etiquette
(4)

Back 126

answer promptly-no more than 3
speak distincly and simply
phone introduction
be conscious of your voice

Front 127

what to do in the phone introduction

Back 127

smile, use full name of hospital, your name, a question offering assistance

Front 128

what should you be aware of in your voice on the phone?

Back 128

tone
speed
volume

Front 129

Other things to keep in mind on the phone

Back 129

be courteous and professional
be a good/active listener
be helpful-write things down

Front 130

placing a caller on hold
(4)

Back 130

Ask if you can
no longer than 90 seconds
offer to have someone call them back
remember how you feel on hold

Front 131

Screening calls

Back 131

be tactful, d/n interrupt vet if it can wait, be aware of ones that vet want to speak to immediately

Front 132

taking messages
(2)

Back 132

always write it down
initial

Front 133

What to record in a message

Back 133

date/time
full name-spelling
summarize the call

Front 134

Client relations
maintaining the right attitude

Back 134

be professional
be courteous and respectful
remember clinet's name/pet's name and gender
good listener

Front 135

client relations
irate clients

Back 135

do not argue
listen and try to understand
let them know you want to resolve the conflict

Front 136

client relations
client grief

Back 136

schedule euthanasia when it is less busy
have tissues
collect fees before
send a card immediately after
acknowledge clients feelings
do anything you can to make the experience easier for client