Medical record
The physical folder for each veterinary patient and the total body of information that comprises each animal history
Veterinary/client/patient/relationship
Interaction between veterinarians and their clients and patients is conducted under the ------and medical records must be maintained for all patients with whom this relationship exists
Source orientated
That veterinary medical records is a medical record format in which patient information is grouped by subject matter clinical observations are entered as they become evident and progress note paragraphs are written in chronological order
Signalmenr
Refers to the collective information that identifies an individual patient such as the species breed gender reproductive status age color and distinctive markings
Previous history
Recorded information such as patient data birth preventative medicine program behavior previous conditions and known allergies are included as part of the
Problem orientated
Through the use of the----veterinary medical records and organized approach to clinical veterinary care is achieved as information is grouped by problem and each problem is assigned a number and addressed individually
SOAP
Structured system of documenting patient evaluations and assessments in the progress notes is called---format
Recent history
Patient information such as presenting complaint current medications location and character a problem treatment efforts and recent changes in the environment may be included as part of the---in a comprehensive medical record
Master problem list
Major medical disorders experienced by a patient during the lifetime are included in the---which serves as an index to the patient's medical history
Working problem list
Veterinary practices will often use the---to assist the veterinary healthcare team when working through current patient problems
Progress notes
The ongoing daily management of hospitalized patients is documented in---so that the therapeutic treatment and plans may be evaluated and adjusted accordingly
Technician evaluations
Hypothermia, altered mentation, inappropriate elimination, and risk of infection are examples of----according to the vet nary technician practice model
MAOR
To ensure that a hospitalized patient is given the treatments, diagnostic tests, and diet requested by the veterinarian the----or ward treatment sheet is used
Veterinary medical database
A national data bank, called the----contains computerized veterinary medical data supplied by 24 hour veterinary schools in the United States and Canada for studies of national trends in various Animal diseases
Subjective
Awake, standing, wagging tail
Subjective
Lithargic, not eating well, lying in right lateral recumbency
Objective
Temperature, weight, capillary refill time
Objective
Heart rate, respiratory rate, skin reaction time
Assessment
Cardiac insufficiency, hypotension, decreased perfusion
Assessment
Anxiety, acute pain, reduced mobility
Plan
Limited daily exercise, cold compresses to injury
Plan
Antibiotics prescribed, Hypoallergenic diet, follow up appointment
Priority 1 -oxygenation
Dyspnea,Blue mucous membranes, oxygen level 89% on poles oximetry
Priority 2- critical safety and/or severe pain
Body temperature at 94�F, acute abdominal pain, chemistry panel K1 5 1.2 MMOL\L
Priority 3- hydration
Delayed recovery of skin tenting, weak peripheral pulses, tacky mucous membranes
Priority 4- elimination
Urinating in the house, urinating more frequently, unable to hold urine overnight
Priority 5-nutrition
Bleeding gingiva, halitosis, difficulty chewing
Priority 6-noncritical
Deep sores caused by licking, scratching at ears; owner won't use an Elizabethan collar as directed
Priority 7-chronic pain or mild-moderate acute pain
Moaning frequently, reluctant to move, tail tucked between legs
Priority 8-activity
Restless at night, gets up slowly, pants heavily when exercised
Priority 9-utility
Anxious, fearful, displays submissive urination
TRUE
The medical records can be used as a legal document in a court of law and can be a critical importance in defending against malpractice suits
TRUE
Only approved standard abbreviations should be used in medical record keeping
TRUE
When using Source orientated veterinary medical records clinical observations are entered as they become evident so that the most recent information is located last
TRUE
The American animal hospital association endorses the use of problem oriented medical record keeping for practices seeking AAHA certification
TRUE
When recording physical examination results abbreviations such as BAR, & WNL should not be used because they may be interpreted differently by other vet nary healthcare providers
TRUE
The POVMR working problem list helps veterinarians and veterinary technicians think critically identify and prioritize problems and formulate an understanding of the patients reactions to an illness
TRUE
Medications admin/orderRecords should include The patients full name patient ID number and\or signalment and any known allergies that the patient may have
TRUE
The American animal hospital association requires that paper records for each patient should be stored in standard 8 x 10" folders
TRUE
The primary medical record collection should include active records covering a three-year period
TRUE
I necropsy log contains data regarding an animal's death, the owners name, species, name of the veterinary performing the necropsy, Histopathology, and gross findings
TRUE
According to DEA regulations schedule II controlled drugs must be maintained in the separate inventory record
TRUE
Records for schedules III, IV, V drugs may be combined into one log but must be stored separate from other practice records
TRUE
Electronic record entries made within the first 24 to 48 hours of a patient care are regarded as primary documents
TRUE
And excepted medical record keeping practice for ambulatory practitioners is to make handwritten notes on carbonized invoice sheets that are loaded into a sturdy metal dispenser
FALSE
Completed consent and authorization forms provide veterinary practices with legal evidence of informed consent and can be signed by a pet owner of any age
FALSE
Injuries and written records may be corrected using correction fluid provide the entry is signed and dated by the person who made the air with a brief explanation of the correction
FALSE
Veterinary medical records are the property of the pet owner because the client purchased the veterinary services that generator did the medical information
FALSE
The owner of an animal should not be required to sign an authorization form to obtain a copy of his or her pet records for himself or herself
FALSE
If a veterinarian diagnoses a reportable disease, permission from the client to release the patient's record must be obtained prior to alerting local state and federal agencies
FALSE
When documenting treatments on MAOR an X should be placed in the appropriate column at the time of the medication is administered to the patient
FALSE
Medications given during surgical or Anesthetic procedures should be entered on the MAOR along with all the other medications that the patient receives
FALSE
When using the alphabetic system of medical record filing a major disadvantage is that a client cross reference list must be generated and maintained
FALSE
A recommended practice for purging files is to remove and shred all records that have been inactive for four or more years
FALSE
According to the federal comprehensive drug abuse and control act and inventory of all controlled substance is must be made on an annual basis
FALSE
Controlled drugs that are considered the most addictive are in the schedule V category