3.1 Explain the purpose, the proper format, and the components of medical records
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Veterinary Medical Records
3.1 Explain the purpose, the proper format, and the components of medical records
Veterinary Medical Records
Read this assignment. Then, read from the "Introduction" to the section titled "Management of Paper Medical
Records" in Chapter 3 of your textbook.
After completing your reading assignments, complete the chapter activities in your
Clinical Textbook for
Veterinary Technicians and Nurses
workbook for Chapter 3. Please don't complete the case studies in the
workbook at this time. You can check your answers with the answer key provided.
Introduction
Veterinary medicine requires careful documentation. Every examination, diagnostic test, medical treatment, or anything else that's done to a patient must be carefully recorded, in detail, so that anyone who reviews the record is able to follow along with that patient's care.
The medical record
is made up of all handwritten or typed records regarding the patient, all laboratory data, all surgical and anesthetic records, all client communications, all specialist referrals, and any other documented information regarding that patient. In many practices, all of this information is stored in a computerized practice management system.
Functions of the Medical Record
Medical records serve a number of important purposes. These can be categorized as primary purposes and secondary purposes.
Primary Purposes
The two primary purposes of medical records are as follows:
1.
Support excellent medical care: Medical records prevent confusion among members of the veterinary team and contribute to the formation of appropriate diagnostic and treatment plans. Reviewing a medical record will allow a team member to monitor a patient's response to treatment and provide continuity of care. The medical record provides for continuity of care by reminding a veterinarian of the physical exam findings on a patient, the patient's history, tests that have been performed, the results of these tests, the diagnosis, the treatment that has been initiated, and all comments and recommendations made to a client. A medical record provides continuity when multiple doctors are involved in a single patient's care by providing the medical history, current problems, and what's planned for the patient.
2.
Document communications: Medical records provide a way for members of the veterinary team to document their communications with clients. The medical record contains contact information for the client. Quick access is important when a decision must be made about a particular treatment or procedure.
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Veterinary Medical Records
3.1 Explain the purpose, the proper format, and the components of medical records
Secondary Purposes
There are two secondary purposes of medical records:
1.
Support business and legal activities: Medical records can be used for invoicing and other practice management functions, and also as legal evidence in case of a lawsuit.
2.
Support research: Information from medical records can be used to create databases that aid in studies
of veterinary diseases. For instance, how many cases of canine heartworm were detected in the practice within a certain time period? How many limb fractures of a specific type has the practice seen? Veterinarians can gather information about the makeup of their overall patient base by using medical records. For instance, it's possible to determine how many dogs of a particular breed, or how many cats of a particular age, are in the patient pool.
Medical and Legal Requirements
There are a number of legal requirements involved in the practice of veterinary medicine. Accurate, detailed medical records are the best way to verify that these requirements are being met with each patient.
Veterinarian-Client-Patient Relationship
The veterinarian-client-patient relationship (VCPR)
is the basis for all interactions between veterinarians, their clients, and their patients. A medical record is required for every patient with whom a veterinarian has a VCPR.
There are three requirements to claim that a VCPR exists:
1.
The veterinarian has assumed responsibility for the animal's medical care and the client has agreed to follow the veterinarian's recommendations.
2.
The veterinarian has enough familiarity with the animal to formulate at least a preliminary diagnosis. This means that the veterinarian has either recently examined the individual animal or examines the animal's premises on a regular basis.
3.
The veterinarian is available for follow-up/emergency coverage (or has arranged for such coverage) in the event of an adverse reaction or treatment failure.
Documentation in the medical record allows a veterinarian to affirm that all of the previous conditions are being met when providing treatment for a patient.
Informed Consent
The medical record serves to document that a client has given informed consent
to any particular test or treatment. Informed consent means ensuring that the client understands all possible aspects of any test or treatment. These aspects include costs, risks, and expected benefits. The medical record should contain documentation of efforts that were made to inform the owner before acquiring consent, such as spoken conversations, written instructions, and email interactions.
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Veterinary Medical Records
3.1 Explain the purpose, the proper format, and the components of medical records
When consent is given via telephone, especially for risky or expensive procedures, it's always best to have a second witness confirm with the client that informed consent is being given. For example, if a client authorizes
the euthanasia of her pet during a telephone call with her veterinarian, the veterinarian may hand the phone to a nearby veterinary technician to verify the client's wishes. After this conversation, the veterinarian and technician would both document in the record that they've received the client's consent. This decreases the likelihood that a clinic would ever be found guilty in the event that a client claimed that they didn't authorize something via telephone.
In most practices, written consent forms are used for procedures that may have a higher risk of misunderstandings. These may include surgeries, anesthetic procedures, euthanasia, and expensive diagnostic
tests. Consent forms typically cover the expected risks and benefits of a procedure, while a written estimate is typically presented for an owner to sign to avoid miscommunications over finances.
Protection Against Lawsuits
Although all members of the veterinary team hope to avoid lawsuits, the reality is that any veterinarian or veterinary technician could find themselves subject to a lawsuit at some point during their career. Accurate medical records serve as evidence in the case of a lawsuit, while inaccurate or incomplete records can serve as
evidence of incompetence or substandard care. In general, the phrase "if it's not in the record, it didn't happen" is used in legal proceedings between clients and members of the veterinary team. Therefore, records should always be complete and thorough.
Additional steps that can help ensure complete, accurate records include the following:
Entries should be typed or neatly handwritten.
All entries should be signed or initialed by the author, ideally with a date/time stamp. (Most practice management software systems do this.)
In written records, nothing should ever be erased, whited out, or scratched out. Errors should be corrected with a single line and a signed/initialed note explaining the correction.
Only standard abbreviations should be used.
States may have their own additional requirements for medical records. Therefore, it's important to review your state's practice act and rules and regulations prior to beginning your career as a veterinary technician.
Ownership and Release of Medical Records
Although the clients have authorized and paid for the services documented in the medical record, the record belongs to the veterinary practice. Clients are permitted to request a copy of their pet's medical record, and this request must be granted. Practices are allowed to charge a small fee to cover the expense of copying and sending the record.
Veterinary records are to be kept confidential, except in rare circumstances (reportable diseases or records that are subpoenaed by the court). Records should be released to a third party only with the written consent of the pet owner. Clients may request to have their records transferred to boarding or grooming facilities, other veterinarians, pet insurance companies, or others.
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Veterinary Medical Records
3.1 Explain the purpose, the proper format, and the components of medical records
Veterinary Record Formatting
Traditionally, the medical record in the veterinary office has been a manila folder containing client and patient records, or an index card kept in a small filing cabinet. More and more veterinary practices are becoming paperless as staff members adapt to using computers and as useful programs are developed. With electronic records, several people in different locations in the clinic can use the same file at the same time. The ease of retrieving computer files makes computer records superior to paper records.
Practice information management systems (PIMS)
now allow pictures, radiographs, and lab results to be added to the patient's record, items that previously required a place for storage. Some systems enable the veterinarian to dictate notes directly into the record. Software programs for medical and financial inventory and scheduling are being written specifically for the veterinary practice. In the past, programs had to be modified for animal use.
A computer minimizes transcription and spelling errors and the inevitable misplaced record. Some programs even send out reminder notices to clients or remind staff members that certain clients need to be called.
One of the fears many veterinarians have about computer records is the possibility of the computer "crashing"
and losing data. Backups, if used routinely and stored properly, can alleviate this fear. If a backup is done daily,
and the system fails, only a small amount of data will be lost. A master backup should be kept off-premises in case of a catastrophic event.
Regardless of whether a practice uses traditional paper records or a computerized system, there are two primary approaches to medical record organization. Most practices use one of these two techniques or a hybrid of the two.
Source-Oriented Veterinary Medical Record
The source-oriented veterinary medical record (SOVMR)
groups information by subject. For example, laboratory results may be kept in one area of the record while progress notes are kept in a separate area of the record.
Records are typically kept in reverse chronological order
, with the most recent records being found first. These records can be complicated to review, because information must be looked for in several different locations.
Problem-Oriented Veterinary Medical Record
The problem-oriented veterinary medical record (POVMR)
groups records by problem, with each problem being addressed separately. Notes are recorded in SOAP format, and these notes may be entered by a veterinarian or technician. This type of medical record is endorsed by the American Animal Hospital Association (AAHA) and is thought to foster a team-based approach to patient care.
While it's more time-intensive to keep this style of medical chart, it improves communication among staff and among doctors in a multidoctor practice. More historical information and other data are readily available to support care planning and provide legal protection if a claim arises.
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Veterinary Medical Records
3.1 Explain the purpose, the proper format, and the components of medical records
Components of the Problem-Oriented Veterinary Medical Record
Although there are differences between POVMRs, most include similar components.
The Database
The database
consists of all information available about the patient. This includes a number of distinct components.
The first component of the database is the client/patient information. Client and patient identification are typically entered by the receptionist, either at the time that the appointment is scheduled or when the client checks in for the appointment. This information includes the patient's signalment
: name, age, sex, reproductive status (intact, spayed, neutered), and breed.
This is followed by the history
, which may include both previous history details (such as origin, preventive care
status, behavior, environment, diet, allergies, and other previous history) as well as recent history. The recent history is often emphasized unless the patient is new to the practice, and focused on the presenting problems.
Important considerations in the history include the following:
Presenting complaint
When the problem started
Description of the problem
Current medications
Current diet
Recent changes in environment or household status
Other information from the client or prior veterinarians
The history is followed by the results of the physical examination. Each body system is examined and, in most practice management software systems, results are entered for each individual body system. Normal findings are typically abbreviated as WNL
, which stands for "within normal limits." Another commonly used abbreviation is BAR
, which stands for "bright, alert, and responsive."
The next section of the database includes laboratory results, anesthetic recordkeeping sheets, and other additional information. This may include results that are automatically transferred into the PIMS from the laboratory machines or printed records that are scanned or otherwise added into the record.
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Veterinary Medical Records
3.1 Explain the purpose, the proper format, and the components of medical records
Master Problem List and Working Problem List
The master problem list
contains a list of all medical disorders experienced by a patient over the course of its lifetime. This list contains a final diagnosis for each problem that the patient has had addressed in its past.
The working problem list
is designed to help the veterinary team address current medical problems. This list is
often focused more on clinical signs than diagnosis, because a diagnosis may not be known at the time that the problem is being addressed. For example, a problem may be listed as "diarrhea" in the working problem list, but may later be further defined as "inflammatory bowel disease" in the master problem list after appropriate diagnostics.
Hospitalized Patient Records
Hospitalized patients should have thorough medical records that are kept updated throughout the course of their hospitalization. These records should include all treatments, procedures, and test results. Client communications (status updates, authorization of tests/treatments, and so on) should also be included.
While patients are hospitalized, technicians may enter their SOAP notes
. These notes consist of four sections:
S
: Subjective
. This section contains subjective information such as patient history and subjective impressions. Subjective data are entries that describe the animal's overall attitude, such as "bright, alert, and responsive." Subjective information about a patient isn't measurable with the same detachment as the objective variables. The subjective entries comprise the overall clinical impression of a patient, answering such questions as "How does the animal move?" and "How does the animal respond to its environment?"
O
: Objective
. Objective information includes factual, measurable data, such as an animal's weight, body temperature, heart rate, respiration rate, results of laboratory analyses, interpretation of radiographs, and results of an electrocardiogram.
A
: Assessment
. This section summarizes the conclusions that can be made based on the subjective/objective observations. For example, the technician evaluation may state that the patient is hypothermic, in pain, and showing signs of infection.
P
: Plan
. This section describes the steps that must be taken to correct any abnormalities noted in the assessment.
In addition to SOAP notes, the records of hospitalized patients often contain a medication administration/order record (MAOR)
. This document, also known as a treatment sheet
, is used to track treatments and diagnostic tests that have been ordered by the veterinarian. These sheets may be hung on a patient's cage, allowing the veterinary team to assess quickly what treatments are needed by a particular patient and sign off on (or initial) these treatments as they're completed.
When a patient goes home after hospitalization, copies of all discharge/summary forms that are sent home with the patient should remain in the pet's medical record.
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Veterinary Medical Records
3.1 Explain the purpose, the proper format, and the components of medical records
Key Points
Although the primary purpose of veterinary medical records is to support patient care and document client communication, records also can support the business and legal interests of a practice, and have implications for veterinary research.
Medical records document the existence of a VCPR and informed consent.
Although multiple formats for medical records exist, many practices use a problem-oriented veterinary medical record, with progress notes entered in SOAP format.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1.
What are the two primary purposes of a medical record?
Supporting excellent patient care and documenting client communications
2.
What are the three requirements for a VCPR to exist?
The veterinarian has assumed responsibility for the animal’s medical care, and the client has agreed to follow the veterinarian’s recommendations. The veterinarian has either recently examined the individual animal, or examines the animal’s premises on a regular basis. The veterinarian is available for follow-up/emergency coverage (or has arranged for such coverage).
3.
What's the meaning of "informed consent?"
Informed consent means ensuring that the client understands all possible aspects of any test or treatment, including cost, risks, and the expected benefits.
4.
List the four sections of a SOAP note.
Subjective, objective, assessment, plan
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Veterinary Medical Records
3.1 Explain the purpose, the proper format, and the components of medical records
VCPR
Veterinarian-client-patient relationship
Informed Consent
Consent that is given after a client is educated on the pet’s condition, diagnosis, prognosis, and treatment options
Reportable Disease
A disease that must be reported to government officials because it is dangerous to the public or to widespread
animal health
SOAP Format
A format for medical notes that consists of subjective, objective, assessment, and plan sections
Signalment
Information that identifies an individual patient
WNL
Within normal limits
BAR
Bright, alert, responsive
Master Problem List
A list that includes all major medical disorders experienced by a patient in its lifetime
Working Problem List
A list of a patient’s current medical problems that the veterinary team is working through
Medication Administration/Order Record (MAOR)
Also known as a ward treatment sheet, this document ensures that hospitalized patients are given treatments as requested by the veterinarian
Consent Form
A written form, signed by a client, that is used to document informed consent
Source-Oriented Veterinary Medical Record
A medical record format in which information is grouped by subject matter
Problem-Oriented Veterinary Medical Record
A medical record format in which information is grouped by problem
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