Record Keeping
Accurate and complete records are essential in small animal veterinary practice.
What Needs to Be Recorded?
Veterinary medical records include forms, documents, and logs which record the treatment and care of animal patients. These are dynamic documents that record the sequence of events each time the veterinarian sees or communicates with that particular pet o
How is it Recorded?
Veterinary medical records are considered legal documents and as such must be treated by certain rules. All records must be written legibly in ink - preferably blue or black (never red), and never in pencil.
No records should be erased, whited-out or comp
Objective Information
Includes factual, measurable data such as body temperature, fecal float results, x-ray interpretations.
Subjective Information
Involves the overall clinical impression of a pet and is not measurable by any standard. It can be as simple as a phrase such as "bright, alert & responsive".
Rules for Veterinary Medical Records
A. Veterinary medical records are an integral part of veterinary care.
B. Medical records are the property of the practice and the practice owner.
C. Ethically, the information within veterinary medical records is considered privileged and
confidential. I
How Long Do You Keep Records?
Most records must be kept from 5-7 years. Check with local veterinary association. X-rays are also legal records and must be retained for the same period of time. Records may be removed from the main filing system (inactivated if the animal isn't coming i
Organizing Records
There are two primary formats of organizing the medical file. These are:
� The source-oriented veterinary medical record
� The problem-oriented veterinary medical record (POVMR)
Source-Oriented Veterinary Medical Record
This method, also called the conventional format, enters information into the record as it occurs chronologically. The file therefore ends with the most recent entry. The conventional format is easy to learn and requires less time to complete. In addition
Problem-Orientated Veterinary Medical Record (POVMR)
The problem-oriented veterinary medical record format provides a complete, accurate, detailed accounting on the patient. POVMR offers improved professional communication by providing a complete compilation of the patient's problem along with any treatment
SOAP
S - Subjective information
O - Objective information
A - Assessment of the problem
P - Procedure or plan of action
Abbreviations
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MPL
Master problem list
MAR
Medication administration record
Dx
Diagnostic plan
Rx
Therapeutic plan
CE
Client education
Keeping Records Up to Date
One of the most important aspects of medical record keeping is accuracy. It is critical that each medical record always reflects up-to-the-minute information about a pet and the client. As the clinic receptionist, you will be responsible for all financial
Common Record Abbreviations
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A
Assessment
POVMR
Problem Oriented Veterinary Medical Record (method of recording format)
RC
Recall - client needs to be called within or at a certain period of time.
RM
Reminder - for vaccine (v), heartworm (h), geriatric (g), pediatric (p) or dental (d) are pre-coded so they can be input into the computer for auto reminders.
TDx
Tentative diagnosis
Record Filing Systems
When a patient's medical record is not readily located, the statement "I can't find your pet's medical record" is an admission of a disorganized hospital. As such, clients instantly begin to lose confidence in you and our hospital's medical services. They
Numerical Filing Systems
Numerical filing is done by one of two formats: either each client is assigned a number or each pet is assigned a number. Normally each basic digit, 0 through 9, is assigned a different colour. File folders ( especially end-tab folders ) are used to hold
Alphabetic Filing Systems
The client's last name is used as the file identification and as the method for systematic file storage. Each letter of the alphabet is assigned a colour, and the first 2 or 3 letters of the last name are attached to the end tab of the medical record fold
Colour-Coding
Color can increase filing efficiency by 90%. Folders can be color-coded with one-piece strip labels according to the exact requirements. The most common color-coding systems (Alphabetic, Numeric or Terminal Digit) can meet any particular filing needs.
Pet's File
Record filing systems can be as easy or complex as desired. Most commonly every animal will have its own file. Occasionally, animals like puppies will be grouped together under their mother's file. Or breeders may have a file for various rarely seen anima
Logs
There are many different logs that need to be maintained in a veterinary clinic. A log allows a quick check for necessary information without pulling patient files or going to other lengths to obtain information. Some governmental regulations require logs
Types of logs used and the information usually included are:
...
Controlled Drugs
Essential for drug accountability with regard to narcotics, anesthetics, Log and other Federally controlled substances. Usually inspected periodically by Health Canada.
Anesthesia/Surgery
Helpful for callbacks, and to gather information on #'s of types of Log procedures, surgery times, and other stats. Date, animal's name, procedure, drugs used, length of time, people involved.
Dental Log
Similar to sx log.
Special Orders Log
Keeps track of client requests and when items have been ordered and picked up. Date, name, phone number, item they want (specifics), date ordered, date client called, date item picked up.
Reorder Log
Usually some place to write items that are running low (pharmaceuticals, testing agents, clinic supplies, vaccines, stationary, etc.)
Euthanasia Log
Helps to keep track of euthanol or other euthanizing agents, and whether cremation services were used or how the pet was disposed (need for accounting) Date, name, doctor, amount of euthanol, type of disposal.
Laboratory Procedure Log
Quick reference to see what tests were done for what animal what day, instead of checking files. May have one for in house tests
and one for samples sent to outside laboratories. Name, pet, date, what was done, results.
Courier Log
When was courier called, and when was item picked up. (For accounting)
X-Ray Log
Quick reference to note when and what technique was used for particular pet. Record client, pet, date, body part, positioning, exposure settings, films used.
Maintenance Log
Ways to make sure that certain maintenance is done at certain intervals, and to check back to see what has been done. May have one for every clinic machine or piece of equipment.
Cash Out Log
Record of cash drawer balancing - problems, date, people involved.
Boarding Log
Owner, pet, duration, which kennel, problems, when discharged, fee.
Grooming Log
Owner, pet, type of cut, any products used/dispensed, sedation if used.
Cleaning Log
How often things need to be cleaned, and whether it was done and who did it.
Biopsy Log
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Necropsy Log
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Fax Log
Who sent, from whom received, problems, date & time.
X-Ray Log
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