Ethically, information in a patient chart is:
confidential
legal issues, research, and medical business information are all __ medical record purpose
secondary
__ prevent confusion of patient and client identites
medical records
Diagnosis, prognosis, and treatment are all __ purpose of a medical record
primary
by law, controlled drugs must be inventoried how often?
every 2 years
for which procedure is a consent form needed?
euthanasia procedures
for what procedure is a consent form needed
euthanasia procedures
to maintain confidentiality, __ is removed from records before they are used for teaching
patient markers
if you work in a "paperless" office, using an off-site service to store electronic medical records means
this service can act as a third-party agent to verify the absence of tampering
general medical records are typically owned by the:
practice and practice owner
data in a medical record must not be:
erased or scratched out
paper records are required to be stored:
in standard 8 by 10 inch folders
the two most common types of paper folder systems are:
alphabetical and numerical
a separate inventory record must be kept for each schedule __ drug
II
farm animal veterinarians keep __ immunization records on large numbers of animals
combined herd
in a __ oriented veterinary medical record, or SOVMR, recent information is kept together by subject matter
source
in a __ veterinary medical record (POVMR), information in the medical record is grouped by problem, and each problem is assigned a number and addressed separately
problem-oriented
in a SOVMR, clinical observations and progress notes are added in what way
chronologically
the major drawback of SOVMR documentation is that:
individual medical problems may be difficult to monitor
signalment is the term used for
patient identification information recorded in a medical record
the patients history does includes:
preventive medicine programs, known allergies, behavior information
WNL is an acronym for:
within normal limits
in the POVMR, the patient information, physical examination findings, and diagnostic test results are collectively known as the
database
the __ problem list serves as an index to the patients medical history
master
the __ problem list helps the clinician to list clinical signs as they become apparent without offering a specific diagnosis.
working
ongoing management of the veterinary patient is documented in __ notes
progress
the S and O in SOAP stand for __ and __
subjective, objective
the A and P in SOAP stand for __and __
assessment, plan
what form is used for recording the laboratory data collected from an animal
diagnostic flow sheet
the completed authorization form that provides the veterinary practice with legal evidence that the owner has been informed of important information and has agreed to pursue a certain action is the __ form
doctrine of informed consent
what are some logs typically kept in a veterinary office
anesthesia and surgery log, euthanasia and controlled drugs log, ultrasound and laboratory log
what log is helpful for technicians who wish to improve exposure techniques
radiologic procedures log
what categories of controlled drugs is the most addictive
schedule I
the controlled drug log must have pages that:
cannot be easily removed
what acronyms refers to a sheet that offers information on a patients management during hospitalization, including which treatments were delivered, when and by whom
MAOR
a cage card:
is used to identify the patient and the reason for hospitalization
the __ supports the advancement of research in veterinary medicine by allowing studies of national trends in various animal diseases
VMDB
ADR
aint doin right
BAR
bright alert responsive
TPR
temp, pulse, respiration
WNL
within normal limits
QAR
quiet, alert, responsive
MM
mucous membrane
NSF
nothing significant found, no significant findings
BCS
body condition score
CRT
capillary refill time
TX
treatment
SQ
subcutaneous
NPO
nothing orally
RX
prescription
PRN
as needed
R/O
rule out
DX
diagnosis
SX
surgery
IV
intravenous
IM
intramuscular
IP
intraperitoneal
ID
intradermal
TD
transdermal
IC
intracardiac
PO
by mouth
IA
intraarticular
SID
once a day
AD
right ear
EOD
every other day
BID
twice a day
AU
both ears
QID
four times a day
URI
upper respiratory infection
UTI
urinary tract infection
OS
left eye
AS
left ear
OU
both eyes
q_h
every_hour
BP
blood pressure
TID
three times a day
OD
right eye
C/S/V/D
coughing, sneezing, vomiting, diarrhea
wt
weight
kg
kilogram
EAG
express anal glands
NT
nail trim
CBC
complete blood count
ECG
electrocardiogram
OHE
ovariohysterectomy
CV
cardiovascular
GI
gastrointestinal
LN
lymph nodes
SOAP
subjective, objective, assessment, plan
in dogs and cats, the pulse rate is most often evaluated over the:
femoral artery
what body system does observation of the nose for nasal discharge often begin the examination
upper respiratory system
T/F acute moist dermatitis is also known as a "hot spot
true
T/F a thorough physical examination is often the first and most important diagnostic test performed on a patient
true
midabdominal palpation of a normal dog or cat will most likely reveal:
primarily intestines slipping between the palpaters fingers
the condition of having an uneven pupil size is called:
anisocoria
what neurologic test involves tapping the limb to see if there is a reflex of the pets stifle
patellar reflex
T/F the palpebral reflex is where you shine a light in the eye and watch for constriction of the pupil
false. its the pupillary light reflex. palpebral reflex is tapping the medical corner of the eye
a normal capillary refill time (CRT) is
1 to 2 sec
the condition of the lower eyelid rolling inward is called
entropion
what is a characterized by a yellowing of the skin and eyes
icterus
the __ system is the most technically difficult and time consuming to examine completely; therefore a complete examination of this system is usually reserved for the patient with a known or suspected disease of this system
central nervous
mucous membranes are normally __ in color and are often observed __
pink, on the gingivae over the upper canine tooth
the best way to calculate the pulse rate is to
count the number of pulses palpated for 15 sec and multiply by 4
a normal ocular examination generally includes
a white sclera
in dogs and cats, the pulse rate is most often evaluated over the
femoral artery
what are the normal TPR values for a cat
temp: 99.5-102.5
pulse: 110-220
rate: 24-48
the heart rates of small breeds of dog are generally __ those of large breeds of dog s
faster than
difficulty breathing due to stenotic (constricted) nares is most commonly seen in which kinds of dogs
brachycephalic
T/F fleas can cause alopecia in a cat
true
hyperthermia can be caused by
anxiety, neoplasia, infection, inflammation
T/F you can effectively perform a physical examination on a pet starting with different body systems each time
false. you should follow a consistent routine and in the same order each time
during digital rectal palpation of an intact male dog, the normal prostate gland can be palpated as
firm, bilobed, and not painful
the client is usually most concerned with the "chief complaint" which is
the reason the client brought the animal in for evaluation
what is characterized by a yellowing of the skin and eyes
icterus
what body parts or parameters is included in a complete integumentary examination
interdigital areas
the best way to obtain a respiration in a painting dog is
hold their mouth closed
a question about whether a dog is taking heartworm prevention is part of the dogs
medication history
T/F if you are looking for a pulse deficit you are listening to the heart with a stethoscope and feeling over the femoral pulse at the same time
true
what are the 5 peripheral lymph nodes in a dog/cat and indicate where they are located
submandibular-under jaw
prescapular-chest area
axillary-armpits
inguinal-groin area
popliteal-caudal to the stifle
T/F tapetum lucidum is another name for the ear drum
false. tympanic membrane is another name for the ear drum
cyanosis is a
bluish tint that usually indicates extremely low oxygen content in the tissue
T/F the anal sacs are located at the 10 oclock and 2 oclock position
false. 8 and 4
the normal feline heart rate ranges from __ beat/min
140 to 220
a "comedone" is a
blackhead
T/F FORLs are not painful to a cat
false. they are very painful
concerning a complete physical examination, accurate statement
measurement of the vital signs is an important part of the complete physical examination
the term grade refers to the __ of a heart murmur
loudness
T/F nuclear sclerosis is a serious ophthalmic disease in dogs
false. it is a normal change of aging pets
once a new patient is placed in an examination room, the first aspect of his or her visit usually involves the veterinary technician or veterinarian
obtaining a complete medical history and performing a physical examination
what are the normal TPR values for a dog
temp: 99.5-102.5
pulse: 60-180
rate: 10-30
T/F it is ok to leave a retained deciduous tooth alone in a pets mouth without removing it
false
the section of a patients history that addresses the severity, duration, frequency, progression, trigger situations, time of day, and character of the problem is the
history of the present illness
the signalment of the animal includes
age
concerning the veterinary techicians role in the history-taking for a patient, most accurate statement
even the best veterinarian may be unable to solve the problems of a particular patient without an accurate and complete history
T/F it is not important to obtain a pets weight at each visit
false
list the 7 components to obtaining a pets vital signs
temp, pulse, respiratory rate, mucous membranes, capillary refill time, weight, body condition score
PLR (system)
nervous system
MM (system)
cardiovascular system
trachea (system)
respiratory system
conscious proprioception (system)
nervous system
esophagus (system)
gastrointestinal system
uterus (system)
urogenital system
alopecia (system)
integumentary system
crackles (system)
respiratory system
anal gland (system)
gastrointestinal system
muscle (system)
musculoskeletal system
lump (system)
integumentary system
kidneys (system)
urogenital system
what are classic signs of a dog with allergies
licking, chronic ear infections, scratching, discoloration of the hair
when cleaning the ear, be concerned about
rupturing tympanic membrane, injury to ear canal
signs that the anal glands are full
licking at area, scooting
what to prepare for ear cleaning
cotton, bulb syringe, solution, cotton tipped swabs, hemo stat, mild soap, otoscope
what is needed for pedicure
kwik stop/styptic powder, nail clippers
how far to cut a nail
2 mm above base of matrix/quick
complications from nail trims
minor hemorrhage, deformity to nail
equipment for bathing
artificial tears/ mineral oil, cotton balls/gaze, tub
method of expression that is most effective
internal