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


There are 2 major functions of the There are 2 major functions of the medical recordmedical record


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


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

Health & Medicine

Medical Records