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17 Cards in this Set
- Front
- Back
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VCPR stands for |
Veterinary-client-patient relationship |
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Medical records provide what kind of documentation? |
Systemic |
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Primary purpose of medical records |
Clinically based -supports medical care |
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Secondary purpose of medical records |
NOT clinically based. - supports business activities - supports legal activities - supports research |
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Two types of patient record formats |
SOMR (source oriented) POMR (problem oriented) |
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SOMR (source oriented medical record) |
- organised by subject matter (I.e. lab results, diagnostic imaging, surgery details) |
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POMR (problem oriented medical record) |
Documents complicated medical cases one problem at a time |
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Distinct format for each entry of POMR (4) |
Database Problem list Initial plan of action Notes on progress (SOAP) |
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Database |
Client / pt info History PE findings Lab reports etc. |
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SOAP |
Subjective Objective Assessment Plan |
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Subjective: |
Nonmeasurable - complaint - history - observations / opinions |
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Objective |
Measurable - pe findings - physiologic data (TPR) - Lab data |
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Assessment |
Usually by a Vet - overall status of patient - tentative diagnosis -list of r/o or diff diagnosis |
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Plan |
Usually by a vet - treatment and meds - diagnostic testing - surgery - communication with client |
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MAOR |
Medication Administration/ Order Record "Hospitalisation sheet" -pt name, ID, treatments, doses, routes, cautions |
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Comprehensive Drug Abuse and Control Act |
Regulates the possession of drugs that have potential for abuse by humans |
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Possible causes of an animals illness are termed |
Differential diagnosis |
