1 . 0 2 A N A LY Z E M E T H O D S T O C O R R E C T LY M A I N T A I N V E T E R I N A R Y M E D I C A L R E C O R D S

VETERINARY MEDICAL RECORDS

1.02 ESSENTIAL QUESTIONS

• What is the purpose of the veterinary medical record?• Who owns the veterinary medical record?• How do you create the veterinary medical record?• What is the proper way to record the information

in the medical record?• What is included in the record?

PURPOSE OF MEDICAL RECORDS

• To provide information for each veterinarian and serves as a diary of an animal’s health that is helpful in multiple doctor facilities and to transfer records.• It includes:

1. Patient 2. Client (animal owner)3. Patient history4. Medical/surgical records5. Progress notes6. Lab information

PURPOSE CON’T

• The medical record is owned and is the property of the veterinary facility• Serves as a legal document that is private and

confidential• Allows for the Veterinary-Client-Patient-Relationship

(VCPR) to be established which provides the opportunity for the veterinarian to make judgments regarding health, diagnosis, how to provide care, and the way records are maintained

• Must remain in the facility for 1-3 years although many hospitals keep records for 7 years after last visit

CREATING A MEDICAL RECORD

• A file should include the following sections or forms:1. Client and patient information2. Master problem list with details of a patient’s history

and previous medical problems, vaccines or surgeries

• When writing the medical record, also make a cage card to identify and locate each patient.

CREATING A MEDICAL RECORD

• After treatment is recommended by the veterinarian, an estimate sheet will be prepared with costs listed• Treatment will be reviewed with the client and consent

forms signed• Care will also be reviewed with the client so the owner

can continue to medicate and care for the patient

• The invoice should be placed on top for easy access for all in the veterinary clinic

RECORDING THE INFORMATION IN A MEDICAL RECORD

• All information must be recorded in blue or black ink (NEVER in pencil or other ink colors)• All information should be accurate and legible- if

a mistake is made then place a single line through the error and initial the error, then place the corrected statement after the entry.• Record all communications with clients in the

record and initial• One record per patient

RECORDING THE INFORMATION IN THE MEDICAL RECORD

•SOAP- Subjective, Objective, Assessment, and Plan1.Subjective: animal’s overall

appearance (attitude)2.Objective: vitals- TPR

(temperature, pulse, respiration), weight

3.Assessment: veterinary diagnosis

4.Plan: treatment or procedure

FILING MEDICAL RECORDS

• Paper or computer records are available, but most facilities use a combination of both• Paper- stored in a file with pockets or claps• Computer- various programs exist

• Common filing systems• Alphabetical- usually client’s last name with color code

and first two to three letters of last name• Numerical- client assigned number or each patient

assigned number. With this system each digit is assigned a color and the year is clearly identified.

CONSENT FORMS AND CERTIFICATES

• Consent Forms are used to identify to the client any recommended procedures with prices while patient is under the veterinary facility care• Client signs consent form to show agreement of medical care and

risks• Serves as a legal agreement

• Neuter certificate provides proof that pet has been spayed or castrated and is no longer sexually intact

• Rabies certificate: rabies is legally required and will show proof if an animal bites another person or pet.

• Health certificate: issued if an animal is being transported out of state or out of the country- (includes a physical exam from a vet that states the animal is free of disease and required vaccinations are up to date)

MEDICAL RECORDS AS LEGAL DOCUMENTS

• Staff should protect the personal privacy of clients by maintaining confidentiality.• All information in a record is private and not to be

discussed without approval.• Client should sign a waiver of confidentiality for

release of records.

INVOICING

• Veterinary Assistant should be able to invoice procedures.• Can be completed on paper or with computer

programs.