a brief and complete record on each individual animal
a medical record
we need ___ to provide better care of the patient through thorough recording of every detail regarding case.
medical records
medical records provide for recording of all diagnostic data to establish ___
diagnosis
exists as a legal contract for care of patient and collection of fee
medical record
___ is necessary for income and sale tax documentation
medical record
a ___ must be documented upon performance of task, or written daily
record
what is a visible record of what the hospital is accomplishing
medical records
having a ___ medical record system saves time and money
computerized
a medical record system that will calculate estimates, invoices for you and perform grammar and spell checks on your notes
computerized medical record system
Dr. Grey did a radiograph of Fitos leg. Who owns this record
all medical records are owned by the veterinary practice
all medical records must be kept for ___ years
3
when you make a mistake on a medical record, you are not permitted to use _a_, instead you must _b_ your mistake with a _c_ and leave your _d_ beside it
a. white-out
b. cross out
c. single line
d. initials
if you had to correct an error on a medical record and now you want to put in the appropriate notes, you must first ____ before you make an entry
skip a line
If Fitos pet parent wants a copy of her dogs radiograph she is...
entitled a copy at a "reasonable fee"
what is an acceptable request for medical records to be send to another veterinary hospital
a written request signed by the client, or a fax or email with the clients signature.
3 ways how medical records are a form of proof against malpractice suits
1. proves against negligence, fraud, or imcompetence
2. proves compliance with administration of controlled substance and medications
3. proves the existence of a vet/client/ pet relationship
medical records on controlled substances and medications must be kept for _a_ years from the date _b_
a. 5
b. used
where are vets required to have licenses to keep animals in their custody
NY and CA
Every animal in vets custody needs a record called ___
SOAP
SOAP means ...
subjective
objective
assessment
plan
a diagram that may be downloaded or drawn and put into a record
anatomical models
what needs to be updated each time a pateint visits and each time shifts change
a physical examination
name things that should be on medical records
patients history
vacc status
physical examination
symptoms
diagnosis
prognosis
biopsy or necropsy reports
client education (at home care)
client authorization for patients treatment
discharge summary
fee estimate
what should be separate from medical records and not readily available to all employees
financial info (credit card, cash, check)
medical records also require pet parents info ...
1. pet parents pet
2. street address
3. city and zip code
6. home and cell number
7. spouse name and number
medical records require pets identification info such as ...
1. name
2. species
3. breed
4. sex
5. description
6. vaccine record
7. medication allergies
what is hardware
touchable parts of the system
what tells parts of the hardware how to communicate
operating system
what helps users to perform specific tasks
application software
what manages network, the back up server, and connects all terminals together.
server
taking an animals history means documenting any changes in ...
1. diet
2. lifestyle
3. app & activity
4. Vx
5. PPh
6. C/S
7. V/D
8. Pu/PD
9. weight
10. personality
___ refers to any condition resulting from diet change, access to garbage, toxins, appearance of blood or mucous.
V/D
vomiting/ diarrhea
___ refers to any condition resulting in pruritic, seasonal, contact withother animals or new bedding/ carpet, etc
integument
___ refers to any condition resulting in Pu/Pd, pollakiuia, dysuria, stanguria, dribbling, leaking, hematuria
urinary
___ refers to any condition resulting in dry or moist cough, or cough during activity, or night time
CV
___ refers to a condition resulting to gradual of sudden trauma after exercise affecting one or more limbs, etc
MS
Order of which we examine. example: The ear
1. check external parts (the pinna)
2. check internal parts with an otoscope (the inner ear)
the observance of symmetry, attitude, gait, body condition
distance examination
the observance of ocular, optic, oral, lesions, CRT, odor, coat and skin
close-up examination
feeling for lumps/bumps, abscesses, hematomas, cysts, ascites, CN
palpation
listening for sinuses, in the trachea, thorax and the abdomen
auscultation
#1 rule of doing a physical exam
always examine the patient from the very tip of their nose to the very tip of the tail. do not by-pass any parts
a radiology log is recorded because we want to know 2 things
1. how often the radiograph is used
2. how often we need to do maintenance repairs
a radiology log would contain what information
1. exam date
2. type performed
3. pet parents name
4. animals name
5. case number
6. exposures
7. dvm's name
every patient undergoing anesthesia must have notations in log containing _a_, _b_, and the _c_.
vitals must be noted every _d_
a. pre-med drugs
b. induction
c. amount used
d. 15 minutes
a log kept for tissues sent for histopathology, date, owners name, animals name, species, an tissue type
biopsy log
a log kept for deceased animal tissues that will be thoroughly examined
necropsy log
what info is required on a necropsy log
animals name, owners name, species, date, the tissues submitted, and the DVM performing
which log inst required but kept to know when to bill clients
necropsy and biopsy logs
BAR stands for
bright alert responsive
QAR
quiet alert responsive
H&L
heart and lungs
WNL
within normal limits
NSF
no significant findings
NPR
no pupil response
EENT
ears eyes nose throat
DDZ
dental dz
ENT
ears nose throat
PLN
peripheral lymph nodes
OHE
ovario hysterectomy
CHF
congestive heart failure
H
hydrated
SO or E&D
sign/ euthanasia, euthanasia & disposal
C
coughing
S
sneezing
C/S
coughing and sneezing
V
vomiting
D
diarrhea
V/D
vomiting and diarrhea
MM
mucus membranes
CC
cheif complaint
HX
history
RX
treatment/prescription
FX
fracture
T
temperature
SQ
subcutaneous
FF
force feed
PO
per os
NPO
nothing per os
OU
both eyes
OD
right eye
OS
left eye
OO
ophthalmic ointment
AU
both ears
AD
right ear
AS
left ear
HP
hot pack
P
pulse
R
respiration
TPR
temperature pulse respiration
q 6 hr
every 6 hrs
sid
once daily
bid
twice daily
tid
three times daily
qid
four times daily
eod
every other day
PCV/ Hct
packed cell volume
CVP
central venous pressure
C-
with
QNS
quantity not sufficient
HGE
hemorrhagic gastroenteritis
Et
Etiology
Sig
instruction
RACL
ruptured anterior cruciate ligament
PPHx
past pertinent history
PH
perineal hernia
CDI
clear, dry, intact (refering to an incision)
MI
mitral insufficiency
TTTP
too tense to palpate
SM
systolic murmur
SR
suture removal
UG
urogenital
MS
musculoskeletal
X
express
( arrow pointing up)
increase
(arrow poining down)
decrease
(check)
checked
mcg
microgram
mg
milligram
ml
milliliter
Gr
gram or grain
FeLV
feline leukemia virus
SMA
blood biochemistry
WBC
white blood cells
RBC
red blood cells
Diff
differential count
R/O
rule out
D/C
discontinued
APP
appetite
PRN
as needed
IV
intravenous
IM
intramuscular
SQ
subcutaneous
3 reasons for restraint
1. control of a procedure (minimum restraint)
2. to prevent animal for hurting itself
3. to protect yourself
true or false
a client may restrain their pet if needed
false. clients never restrain their pets!
three types of restraints
1. verbal
2. physical
3. chemical
name some physical restrainers
leashes
muzzles
ropes
rabies pole
blankets and towels
minimal collars
name some chemical restrainers
1. dexDomitor
2. benzodiazepines IM
how do you decide what restraint is appropriate
judge what type of procedure it is and how much restraint is necessary
OSHA laws
1. blood-bourne pathogen law
2. hazard communication law
3. safety requirements in general industry
4. general duty clause
law that states that "every facility must be safe for every employee"
general duty clause
requires that each employee have an individual training folder which documents all OSHA training, on-going training, and must be continuously updated and kept 3 years after employee has left
general duty clause
requires that each employee have a confidential medical folder that contains document proof of vaccinations or in the event that they decline the vaccine.
general duty clause
requires personal medical files containing pre existing conditions such as medications, blood type, and anything else useful in an event that the employee has an emergency
general duty clause
if you feel you arent protected from hazards in the workplace, it is the employees right, from their employer, to recieve:
1. training on chemicals and other on-the-job hazards
2. OSHA worker standards info on injuries, illnesses, hazards, and workers rights
3. request action to correct hazards or violations
4. file a complaint with OSHA
5. be involved with OSHA's inspection there
6. find out OSHA's conclusion
7. request a research investigation on possible workplace health hazards
