Unit 5 ( Medical Records )

Primary Complaint and History = "S" from SOAP

-Accurately summarize information provided by client -Determine what the client perceives as the problem -Practice manager provides training and monitor records for consistency -General Questions

Must be handwritten legibly in black or blue ink, typed or computer generated

-All entries - Date, time and initialed -No record notation should be erased, deleted, covered with white out or in any way be obliterated -Corrections should be crossed out and correction entered in margin or addendum *Date and initial all corrections *Explanation for correction -Use standard and approved abbreviations

Medical Record Organization

-Client info -Master Problem list -Patient's history -Vaccination status -Problem list -Physical examination -Symptoms -Diagnosis and prognosis -Treatment and progress notes -Biopsy or necropsy reports -Client education re: patient's aftercare -Client's authorization for patient's treatment -Discharge summary -Fee estimate (all hospitalized cases) -Financial information

What's in a Medical Record?

-Client-patient registration forms -Appointment schedules -Client consent and release forms -Patient history -Patient identification records -DVM's medical notes and problem lists -Telephone logs and consultations -E-mail and text communications -Exam room report cards -Client education and instruction handouts -Imaging reports -ECG, electrical exam reports

Additional information in a medical record

-Consultation reports -Prognosis -Surgical Record -Dental Record -Treatment Plans and Consent Forms -Client Discharge Instructions -Euthanasia Authorization

Problem List

-Each problem listed separately -Date active -Date resolved -At a glance, you can see all the active problems

AVMA Ethics and Medical Records

-Integral part of veterinary care. Must comply with standards established by state and federal laws. -Property of the practice and practice owner. Retention by the practice for a period required by statute. -Privileged and confidential information. Released only by owner consent or court order. -DVMs obligated to provide copies or summaries when requested by client. Obtain written release to document request. -Unethical to remove, copy or use medical records without express permission of practice owner.

What is a medical record?

-Legal document -Complete record on each individual patient -"Veterinary medical health information management" *Written and electronic records *Include wide range of forms and logs that document patient treatment and care -Main tool for determining quality of patient care given to an animal by a DVM & hospital staff -Essential for legal defense -State and AAHA requirement -Establishes a legal contract for care of patient & fee collection Necessary for income and sales tax documentation

Treatment - "P" in SOAP

-List of any tests -List of any treatments - meds, fluids, oxygen, surgery, splint -Drugs used and dosages -State pharmacy laws apply (Including labeling for dispensed medication)

Importance of Medical Records

-Must be written daily -Data must be recorded when task is performed -No excuses! -Visible evidence of what the hospital is accomplishing -Functions Primary *Support the patient's medical care Secondary *Evaluations of medical information for business, legal and research purposes9

Physical Examination = "O" from SOAP

-One of most important diagnostic procedures -Record normal and abnormal findings -Structured by body system -Use standard abbreviations

Legal Issues in Medical Record Management

-Owned by veterinary practice (Usually do not belong to client , Clients have the right to examine or receive a copy) -Medical Records must be kept for 3 years - NYS law -Must be handwritten legibly in black or blue ink, typed or computer-generated -Ownership, access, confidentiality and retention vary by state -Owner consent for release of contents:

Subject information

-Presenting complaint, clinical signs as told by owner -Owner observation and interpretations

Summary of Medical and Legal Requirements

-Proof of established vet-client-patient relationship (Can't treat without this relationship) -Enforceable contract for care of animal -Essential for civil/malpractice suits -Defense is better quality records -Compliance with Controlled substances act: Records must be kept 5 years -SOAP every animal in custody: Indication of its treatment

What is a medical record? include wide range of forms and logs that document patient treatment and care which are

-Results of PE, lab tests and diagnostic procedures -Treatment protocol documentation -Patient progress, vital signs, daily observations and monitoring data -Euthanasia and necropsy exams -Owner authorization and consent forms

SOAP stands for

-Subjective Info -Objective Info -Assessment of subject and objective info -Plan based on assesment

Controlled substance log should be in a

Bound composition book

Required Information in Medical Records

Client Identification -Full name -Home and work address -Phone numbers - home, cell, work, fax -E-mail address -Primary method of communication Patient Identification -Name, species, breed, sex, age, description, medical alerts Previous Medical History -Information related to prior health problems -Treatments and responses, surgeries, current medications Vaccination History -Type of vaccination and date given -Whether boosters are required -Reviewed and updated for regular patients -Record location on patient's body of vaccination administration Logs Laboratory Tests and Result Imaging

Plan

Diagnostics, treatment, surgical intervention, client communication

Assessment

Integration of information to form tentative or final conclusion list of all abnormal findings

Assessment - "A" in SOAP

List of all abnormal findings -Diagnosis *Differential - also called "rule-out list" *Definitive diagnoses - what's the difference? *Prognosis

Objective information

Physical exam and laboratory findings

POVMR is organized by

Problem - 2 main features *Master Problem list *SOAP

POVMR stands for?

Problem-Oriented Veterinary Medical Record

Patient Identification

Recorded at time of admission -Name, microchip, tattoo, species, breed, gender, reproductive status, age, color, any distinctive markings Signalment -Used in communication, case discussion, on every patient record (lab reports, etc) -Age, breed, sex, reproductive status

Secondary Purposes- Better Management Through Analysis

Supports business and legal activities -Verifies billing -Supports actuarial calculations *Income analysis *Budgetary plans *Staff workloads *Supports inventory maintenance *Supports formulation of marketing strategy -Supports hospital accreditation -Acts as a legal document "not recorded, not done"

Primary Purposes Unique, Intimate Care

Supports excellent medical care -Identifies correct patient and owner -Supports generation of diagnostic and treatment plans -Supports continuity of care -Supports communication ( Heath team members, Owner, Vet-client-Relation)

Good practice do not _______

release medical record to a third party without owner consent -Obtain consent in writing -Exceptions: protect health and welfare, reportable disease, cruelty