Medical Records
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Transcript of Medical Records
MEDICAL RECORDSMEDICAL RECORDS
Medical RecordsMedical Records
One of the most important and One of the most important and complicated tasks for the hospital complicated tasks for the hospital staffstaff
Veterinary medical records include a Veterinary medical records include a wide range of forms and logs that wide range of forms and logs that document the treatment and care of document the treatment and care of patientspatients
Medical RecordsMedical Records
There are 2 major functions of the There are 2 major functions of the medical recordmedical record
Medical RecordsMedical Records
The primary purpose is to support the The primary purpose is to support the patients medical care by patients medical care by documenting:documenting:
– Diagnostic proceduresDiagnostic procedures– DiagnosesDiagnoses– PrognosesPrognoses– treatmenttreatment
It supports excellent medical care by:It supports excellent medical care by:– Aiding in identification of client and Aiding in identification of client and
patientpatient– It helps in generating an effective It helps in generating an effective
diagnostic and treatment plandiagnostic and treatment plan– Physical exam findingsPhysical exam findings– Diagnostic procedures and tests to be performedDiagnostic procedures and tests to be performed– Records the veterinarians differential diagnoses Records the veterinarians differential diagnoses
ideasideas– Documents patients responses to treatmentDocuments patients responses to treatment– Supports continuity of careSupports continuity of care
It documents communication with the It documents communication with the clientclient
Assists in the generation of reminder Assists in the generation of reminder postcards that help owners stay postcards that help owners stay current with their preventative medical current with their preventative medical carecare
Aids interactions with the clients and Aids interactions with the clients and their petstheir pets
Medical RecordsMedical Records
The secondary purposes include The secondary purposes include evaluations of medical information for:evaluations of medical information for:
– BusinessBusiness– LegalLegal– ResearchResearch
purposespurposes
The medical record lists all the The medical record lists all the services rendered to the petservices rendered to the pet
It verifies services billed to the ownerIt verifies services billed to the owner
It serves as legal evidence of the It serves as legal evidence of the services received by the ownerservices received by the owner
It is also used to assess:It is also used to assess:– Staffing Staffing – Formulate income analysisFormulate income analysis– Help budgetHelp budget– Helps maintains inventoryHelps maintains inventory– Generates marketing strategyGenerates marketing strategy– Plays an important role in hospital Plays an important role in hospital
accreditationaccreditation– Helps assess compliance with standards of Helps assess compliance with standards of
care care
Medical records are used as a legal Medical records are used as a legal document in a court of law during document in a court of law during litigationlitigation
It serves as evidence of procedures It serves as evidence of procedures and treatments performed by and treatments performed by providing specific dates and timesproviding specific dates and times
It is critical in defending against It is critical in defending against malpractice suits malpractice suits
St St
It must be complete and accurateIt must be complete and accurate
In court, if it is not written and In court, if it is not written and initialed, it has not been doneinitialed, it has not been done
Insurance will require to decide Insurance will require to decide whether to pay a claim whether to pay a claim
They are an important element in They are an important element in preparing case studies, research and preparing case studies, research and presentations.presentations.
All patient information (name, etc) All patient information (name, etc) must be removed to maintain patient must be removed to maintain patient confidentiality confidentiality
Types of Medical RecordsTypes of Medical Records
There are 2 major There are 2 major typestypes
Letter size foldersLetter size folders
Pocket card filesPocket card files
Ambulatory large animal practices Ambulatory large animal practices will use carbon forms and/or will use carbon forms and/or computerscomputers
There has been a large shift to laptop There has been a large shift to laptop computerscomputers
Records are not always kept on Records are not always kept on individual animals but on the entire individual animals but on the entire herdherd
Medical records are not subject to Medical records are not subject to the same federal and state the same federal and state regulations as human medical regulations as human medical recordsrecords
The most widely used format is the The most widely used format is the problem-oriented veterinary medical problem-oriented veterinary medical record (POVMR)record (POVMR)
POVMRPOVMR
Is used in teaching hospitals Is used in teaching hospitals
AAHA-accredited hospitalsAAHA-accredited hospitals
Specialty/referral hospitalsSpecialty/referral hospitals
Most private hospitalsMost private hospitals
POVMRPOVMR
Commonly includes the following:Commonly includes the following:– Client patient informationClient patient information– HistoryHistory– Physical examPhysical exam– Master problem list and working problem listMaster problem list and working problem list– Progress notes, assessment, and planProgress notes, assessment, and plan– Pertinent forms: surgery, anesthesia, Pertinent forms: surgery, anesthesia,
radiography, laboratory reportsradiography, laboratory reports– Case summaryCase summary– Fee informationFee information
New client/patient formNew client/patient form
Confirms a valid client/patient/doctor Confirms a valid client/patient/doctor relationshiprelationship
Has to have the finance charge Has to have the finance charge information otherwise it can not be information otherwise it can not be collected collected
Top Page FormTop Page Form
Second Page formSecond Page form
Paper/ Paperless/ PaperlitePaper/ Paperless/ Paperlite