Medical Records Management

Advantages of Computerized Medical Records

-Easy to capture missing charges -Easy to access medical records at any computer station -Can target specific clients quickly and efficiently when promoting specific services -Takes less time to enter information into the computer than to write it out legible -Client perceives progressive, higher quality medicine • Computers take up less space -Eco-friendly; saves paper

Disadvantages of Computerized Medical Records

-Possibility of server crashing -Records can be lost or altered through computer corruption -Computer-generated records can lack medical details

Regardless of the software chosen or whether the records are on paper or computerized, What are the specific criteria every medical record must follow?

1. Each patient must have its own medical record. Multiple animals cannot be listed on one sheet of 8.5 × 11 inch paper. It is acceptable for multiple pets to be in one file folder under the name of one owner, but they must be separated with dividers. 2. Records must be easy to retrieve. Lost records increase staff and client frustration, time, and labor costs. 3. Medical records must be complete and well organized. Each entry should follow a standard SOAP (subjective, objective, assessment, and plan) format that allows the staff to easily follow the progress of the patient. 4. Records should be composed as legal documents that can be admissible in court if needed. 5. Legibility of records is a must! Illegible records can lead to incorrect dosing of medication and protocols.

What are the 8 rules for Medical Records

1. Records must be written in blue or black ink only; no other colors, no pencils. 2. The author of the entry must date and initial each time an entry is made. 3. No correction fluid! 4. When correcting an error in a record, make a single line through the mistake and make the correction. The mistake must be initialed. 5. Use standard and approved abbreviations only. 6. Write in records immediately to prevent the loss of details. 7. Records must be legible! 8. Each continuation sheet must have all the patient information documented on it, including the owner's name and the pet's gender, breed, and age.

True or False: How medical records are maintained depends on each individual clinic. Some medical record systems have evolved with the practice; others may need updating to allow the veterinary practice to become more efficient and provide better patient and client care.

True

Writing illegible medical records is perceived as an incompetency in veterinary practitioners. Use labels to help increase clarity and interpretation.

True

what is within the progress section?

a standard SOAP format

What are Preanesthetic exams?

a standard of care and should be performed on every patient within 12 hours of the anesthetic procedure

What happens when a client is referred to as a specialist

copy of the record should be sent (or emailed), along with relevant images that have been taken (if not in digital form, radio-graphs should be checked out in a log book).

Diagnostic Flow Sheet

is a compilation of laboratory data from a patient that shows results in chronological order

A Master Problem Sheet

is an excellent summary sheet to include at the top of all patient files.

An inactive medical record

is defined as a client who has not been seen by that practice for a year or more. Most states require medical records to be held for at least 3 years; some states may have a requirement to keep them up to 7 years.

Computerized medical records, also referred to as

paperless records

The organization of the medical record depends on practice preference, but most hospitals use a...

reverse chronological order system

Purged medical records

should be shredded to ensure patient and client data never ends up in the wrong hands.

S.O.A.P

subjective, objective, assessment, and plan

Subjective information

the reason for the office visit, the history, and observations made by the client. The opinions and perceptions of the client

True or False: Computerized medical records are the way of the future and increase the efficiency of every veterinary team.

True

True or False: Inactive records must be kept for a certain length of time, (state law varies regarding length of time) and can be purged after a set period

True

What should "A Master Problem" list include?

1. patient name 2. gender 3. species 4. breed 5. age 6. diet 7. allergies (including any to medications, vaccines, or anesthetics) 8. current medications that the pet is receiving 9. any vaccinations the pet has received

What are the purpose of Medical Records?

1. provide an accurate historical account for the veterinary health care team and owner 2. enabling any veterinary team member to continue treatment for the patient 3. provides team members a means of communication 4. alerts them to a patient's special needs 5. serves as documentation for referrals 6. records must be complete 7. legible, and easily accessible at all times 8. clinics may choose to have paper records or computerized medical records

What are the 4 distinct formats each entry must follow?

1. the defined database 2. the problem list (also referred to as master list) 3. the plan 4. the progress section

Paper records are written on......

8.5 × 11 inch paper and usually fastened into a file folder with a two-hole fastener

What is it called records are filed in the computer by both client number and last name?

Computerized medical records or paperless records

Practices that use paper records may file records according to different methods. What is one of those methods?

File Alphabetically.

Objective information

Is gathered directly from the patient; the physical exam, diagnostic workup, and interpretation are included in this section of the medical record. Objective information is factual information

The problem-oriented medical record (POMR)

Is the medical record format most commonly used by veterinary health care teams.

Prognosis

Is the prediction of the outcome of the disease.