Medical Record Setting

2032 Words 9 Pages
Medical Record Documentation in the Veterinary Setting
A record, synonymous with other terms such as, health record or medical record, is a collection of related fields that refers to all the data accumulated regarding the patient’s visit or all of the patient’s visits. The health information professional will find that in relation to the veterinary health medical record, similarities between the veterinary delivery care setting and human health care setting extend to the approach veterinary animal patient medical records are documented and maintained. Michelle Shipley’s article, Choosing the Path Less Traveled, in the Advance Health Care Network for Health Information Professionals, points out similarities between the human health information
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The Veterinary Support Personnel Network is an information hub formed by veterinary technicians and other assistant staff globally (Seibert & Smith, 2014). Seibert and Smith explain that the types of veterinary patient medical record documentation formatting in the veterinary delivery care setting are source oriented medical records format and problem oriented medical records format (Seibert & Smith, 2014). The veterinary delivery care facility can also choose to use a combination of both source and problem oriented medical records. Seibert and Smith define the source oriented medical record as a record in which pages are systematized by discipline, department, and type of form (Seibert & Smith, 2014). The source oriented medical record format entries are frequently prepared in free form text. The most commonly used medical record documentation format is the problem oriented medical record format (Seibert & Smith, 2014). Seibert and Smith state that the problem oriented medical record is capable of providing a more encompassing vision of the patient and supports more consistent and structured method to clinical veterinary medicine (Seibert & Smith, 2014). Problem oriented medical records are largely used in veterinary teaching hospitals, American Animal Hospital Association accredited veterinary hospitals, specialty and …show more content…
Writer, Sue Bowman provides basic information relating as to what the Systematized Nomenclature of Medicine – Clinical Terms is and how it is utilized in the following American Health Information Management Association journal article titled, Coordination of SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems (Sue Bowman, 2005). The Systematized Nomenclature of Medicine – Clinical Terms supports the uniform core of general terminology for an electronic health record, empowering enhanced communication and interoperability of the electronic health record exchange (Sue Bowman, 2005). The Systematized Nomenclature of Medicine – Clinical Terms is a nomenclature information system that encloses codes for diseases and procedures as well as relational terms that can allow the conversion of natural language into a classification system that can also be used in the veterinary health medical records systems (Sue Bowman, 2005). In the veterinary delivery care setting, the Systematized Nomenclature of Medicine – Clinical Terms is utilized by the veterinary facility staff during the course of the animal receiving patient care. Sue Bowman also described how the The Systematized Nomenclature of Medicine – Clinical Terms is put into operation by the input of information as free text,

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