Veterinary Medical Records Study Guide Exam And All Actual Answers.
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Course
Veterinary Medical Practices
Institution
Veterinary Medical Practices
Record Keeping - Answer Accurate and complete records are essential in small animal veterinary practice.
What Needs to Be Recorded? - Answer Veterinary medical records include forms, documents, and logs which record the treatment and care of animal patients. These are dynamic documents tha...
Veterinary Medical Records Study Guide
Exam And All Actual Answers.
Record Keeping - Answer Accurate and complete records are essential in small animal veterinary
practice.
What Needs to Be Recorded? - Answer Veterinary medical records include forms, documents, and logs
which record the treatment and care of animal patients. These are dynamic documents that record the
sequence of events each time the veterinarian sees or communicates with that particular pet or client.
The records are benchmarks and serve as detailed written descriptions of each patient's medical
condition, its progress and its resolution or outcome. In addition to the above purpose, medical records
also facilitate rapid retrieval of patient and client information. Records also provide written
documentation of medical decisions and client consents for legal purposes. This is providing protection
to the veterinarian and clinic staff. Records also provide valuable statistical information about the client
or pet population and how the practice should be headed to meet all the needs and wishes of the public
it serves. The patient record comprises the core of the veterinary patient medical records and is
therefore simply referred to as "the medical record" or "the pet's file". It contains the pertinent facts
about the patient's life and health history.
Information to be recorded includes:
1. Owner's information
A. Names (Include different last names)
B. Address
C. Phone number - more than one is better, and an emergency contact may be good too. Include cell
phone number if have.
D. Client workplace info and phone numbers.
E. Client financial status and methods allowed for payments of services.
Knowing that many people live together these days without being married, it often is best
to ask if there is a "co-owner" in the family rather than a spouse. Established clients should have the
accuracy of their addresses and telephone numbers
verified at each visit. Changes should be made immediately.
, 2. Animal's Information
A. Species
B. Breed & colour
C. Sex and Repr
How is it Recorded? - Answer Veterinary medical records are considered legal documents and as such
must be treated by certain rules. All records must be written legibly in ink - preferably blue or black
(never red), and never in pencil.
No records should be erased, whited-out or completely crossed off. Incorrect entries can only have a
single line drawn through the incorrect information and initialed. The correct information should then be
written down and again initialed. This indicates that an error was made rather than suggesting that
information was changed or tampered with. All entries must be dated and initialed when entered.
Records can be recorded in one of two informational formats:
• As objective information
• As subjective information
Be aware that a veterinary medical record is considered a confidential document but is owned by the
veterinary practice, not by the owner of the animal. Owners have no right nor legal obligation to have an
original record. Any party (owner, insurance, another veterinarian) must sign a release form and then
can only acquire a "copy" of the records. The only party privy to the original would be a legal court of law
or investigating agency such as the police. Even when a pet owner moves to say another province, the
originating veterinarian will only give the new attending veterinarian a copy of the files. The originating
veterinary practice is required to retain all original records.
Objective Information - Answer Includes factual, measurable data such as body temperature, fecal float
results, x-ray interpretations.
Subjective Information - Answer Involves the overall clinical impression of a pet and is not measurable
by any standard. It can be as simple as a phrase such as "bright, alert & responsive".
Rules for Veterinary Medical Records - Answer A. Veterinary medical records are an integral part of
veterinary care.
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