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
Information to be recorded includes:
Owner's information
A. Names (Include different last names)
B. Address
C. Phone number - more than one is better, and an emergency contact may be good too. Include cell phone number if have.
D. Client workplace info and phone numbers.
E. Client financial
Animal's Information
A. Species
B. Breed & colour
C. Sex and Reproductive Status
D. Age
E. Name
F. Source of pet and reason for owning pet
G. Tattoo/Microchip
H. Vaccine Hx
I. Pet's environment and care
J. Medical or physical conditions - ie. Declawed, deaf, blind, diabetic,
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
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 conve
Master Problem List & SOAP
Abbreviations:
MPL = Master Problem List
MAR = Medication Administration Record
S = Subjective data
O = Objective data
A = Assessment of subjective and objective data
P = Plan: May include
Dx - diagnostic plan
Rx - therapeutic plan
CE - client education
I
Subsequent to day 1, a master problem list is generated and each problem on Master Problem List (MPL) which remains active gets at least one SOAP daily.
SOAP for problem #1, lymphadenopthy
S. depressed
O. All peripheral lymph nodes are ~ 4 - 5 times normal size. Cytologic examination of a FNA disclosed lymphoblasts.
A. The above findings are consistent with a diagnosis of lymphosarcoma.
P.DX: bone marrow aspirate to stage the cancer
update
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:
A - Assessment
DDx - Differential Diagnosis
Dx - Diagnosis
O - Objective
P - Plan
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
ReCk - Recheck
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
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 o