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Medical Records

Courtesy of Phil Seibert, CVT and Nanette Walker Smith, RVT, CVT

  • The American Animal Hospital Association (AAHA) established the medical record keeping standards for the entire profession.
  • The "forms" must be tailored to the practice and the philosophy of the veterinarians in charge; there is no single standard of "completeness." However, there are a couple of essentials:
    • Forms going home with clients REQUIRE the practice logo and phone number.
    • Forms being used "in-house" require neither of these, but do require client and patient names.
    • Documentation is the ultimate key. Failure to document often leads to internal control problems, liability/forensic concerns, embarrassment of the practice or client, or a reduced value per pet seen.
    • Medical record keeping is EVERYONE's concern in the practice, period.
    • In quality veterinary healthcare delivery there is ALWAYS time to document everything
    • Record EVERYTHING that is done, AS IT IS DONE
    • Charge for everything that is done.

PUTTING IT TOGETHER

Tracking SheetCharging sheet that travels with the patient record so charges can be circled as they are done
New Client Welcome FormClient/Patient information form completed at the first visit, updated as needed with client/patient personal information.
Patient Data Cover SheetAn overview sheet (master problem sheet) on which all major health problems/issues are documented and can be used as a quick glance for the patient's health status.
Progress NotesFull record of patient notes, clients desires, waivers, deferrals, authorization forms, etc. ALL information should be recorded on these forms.

TYPICAL TRAFFIC FLOW TEN STEP PROGRAM:

  1. Always greet clients and pets with a smile
  2. Greet client with a pleasant salutation and weigh the patient immediately. If it is a new client, the New Patient/Client form is initiated (but may be completed by the veterinary technician in the exam room).
  3. Receptionist begins a procedure tracking sheet and patient progress notes. The presenting problem is entered on the progress notes in the client's own words.
  4. If additional procedures or services are needed, they are added next (vaccines due, ancillary items such as nail trims).
  5. The exam room veterinary technician (VT) escorts the client and patient to the exam room, initiates the health check report card and/or completes a wellness exam. Update any patient info (including others in home).
    1. PHYSICAL EXAMINATION CHECK-UP CARD. The VT performs a TPR, CRT/MMC, a wellness exam, and records a brief history (e.g.: behavior, diet, vaccinations, urine, bowel, appetite, etc.). This is recorded on the Report Card and summarized in the medical records.
    2. Abnormal findings are reported to the client and noted in record for the DVM's review.
    3. Place completed record outside the exam room door and inform the DVM of the appt.
  6. The DVM adds any exam findings or historical factors important to the continuity of care. Problem List entries are made on the Patient Data Cover Sheet with an initial date and a resolved date when applicable.
    1. Regardless of the system selected, a practice shorthand needs to be established, to record what was discussed with the client and the client's response. Both should be clearly annotated.
    2. Subsequent treatment plans are established, reflecting the decisions based on the clinical findings.
    3. Write things only once whenever possible. The plan can show the specific medication and strength while the treatment shows the amount, frequency and duration of use.
    4. Finish with a review: "Let's review what we've done today" is an excellent method of moving to the Patient Data Cover Sheet (use the same codes as the progress notes.)
    5. 3Rs (recheck/remind/recall) are included by the DVM and reviewed with client.
    6. DVM returns record to the veterinary technician for any additional items such as client education, prescriptions, etc.
    7. Veterinary Technician verifies all procedures have been circled on the tracking sheet, and all progress notes have been addressed, and then escorts the client and patient to discharge.
  7. The VT should be preparing another patient to be seen while the DVM does #6
  8. All boxes on the progress notes should be completed prior to the client leaving.
  9. NO medical record should ever go to file if it is missing any of the following key elements:
    • Client complaint
    • Vaccination/preventive health update
    • Assessment(s)
    • Full Prescription information
    • At least one of the three "R's".
    • Check record for tears, loose ID labels, pages, etc. and repair
      • And preferably, that all entries are identified by the person who made them (initialed/signed) and the information is legible.
    1. The medical record should be returned to the patient's veterinarian of record for completion BEFORE the doctor is allowed to depart for the day.
    2. No records should ever leave the clinic overnight, or be out of file overnight.
  10. The procedure-tracking sheet (circle sheet) is used for computer entries and allows for internal controls and tracking of the three "R's." Everything that pertains to the healthcare delivery needs to be in the medical record.

MEDICAL RECORD EFFICIENCY - Other items to use

  1. Mega-stamp or break-and-stick labels (eyes, dermatology, dental, physical, euthanasia, surgical summary, UA, etc.) to illustrate the observations
  2. Receptionists should do final review of completion prior to refiling records and give to the proper person for completion before the end of the day.
  3. Tailor the DVM's appointment schedule to match the individual's style, but also match the practice economics. This includes consideration of variable length appointments, allowing time for treatment of inpatients, etc.
  4. Alternatives provided to the client = needs for the animal or the professional. Do not use the terms: "should, recommend, or it would be best that"; the practice acts specifically state doctors can ONLY provide "needed care" to a patient.
    1. Healthcare needs to be based on the expectation for positive client action now or positive client action later.
    2. Provide the best treatment options for the client; DO NOT pre-judge what they will want or can afford.
    3. If the best level of care is not what the client desires for the pet, record it in the record and attempt to schedule the recheck with the client before departure.
    4. Supplemental forms, if used, should be thoroughly explained and not used as an alternative to talking to clients. The later is counterproductive and should be avoided.
  5. CONTENTS OF MEDICAL RECORDS and patient files are STRICTLY CONFIDENTIAL

HINTS ON HOW TO FACILITATE GOOD PET CARE:

  1. Preanesthetic releases with laboratory test waivers - allows for explanation of the benefits of preanesthetic lab work and offers the client the opportunity to accept or decline.
  2. Discharge forms - provided for review at home AFTER a full discussion has occurred in the practice.
  3. The Unaccompanied Healthcare Form - used for the client to fill out when "dropping off" a patient to be seen without the owner present. (Strongly discouraged)

MARKETING IN VETERINARY PRACTICE:

  1. Make client aware of preexisting needs of the animal (this is also patient advocacy)
  2. Offer the client relief from the concerns about the needs by offering a service that the profession AND practice can now fulfill (this is internal marketing).
  3. Give the client two methods to meet the animal's NEEDS, then be quiet . . . the first person to talk now loses (this is smart business).

HINTS FOR PET LOSS SUPPORT:

Patient advocacy includes grief counseling, compassion, complete explanation of the patient's case, and NOT making decisions for the client. A true patient advocate will tell the owner what is needed and explain the pros and cons.

PEER REVIEW of medical records WITHIN:

Benefits include professional staff development when random samples are reviewed on a recurring basis for content, treatment modalities, forensic concerns, and continuity of care

Example - for use in a staff meeting type format: Start with two inpatient and two outpatient records per doctor per month, selected by receptionist and provided to the staff in copy format. The review must answer the basic questions every professional and paraprofessional should be able to address at any time:

  1. Can I follow this case without embarrassing the practice?
  2. Can I address the client without embarrassing the other doctor, the client, or myself?
  3. Am I willing to stand up in a group of peers and state the animal got the best care possible, from what was written?
  4. When areas of concern are found, steps are taken to correct them.

COMMON RECORD ABBREVIATIONS:

AAssessment
DDeferral - client defers treatment, plan, action
DDxDifferential Diagnosis
DxDiagnosis
HEAPMedical Recording format very similar to SOAP
OObjective
PPlan
POVMRProblem Oriented Veterinary Medical Record (method of recording format)
R/ORule Out - plan to treat for and supports the medicine or actions plan which follows
RCRecall - client needs to be called within or at a certain period of time
ReCkRecheck - patient needs to come back in
RMReminder - for vaccine (v), heartworm (h), geriatric (g), pediatric (p) or dental (d) are pre-coded so they can be input into the computer for auto reminders.
SSubjective
SOAPMedical Recording format (S=subjective; O=objective, A=Assessment; P=plan
TDxTentative Diagnosis
WWaiver - client declines treatment, plan, action

PROBLEM-ORIENTED MEDICAL RECORDS

  • Commonly called the SOAP or HEAP system
  • Organizes history taking and documentation of a single medical problem or episode
  • Organizes entries chronologically by the medical problem or episode
  • Places certain elements of the case in the same order for every entry

S (or H)= Subjective Information - information supplied by the client.

  • Presenting complaint from the client and the pertinent medical history.
  • Do NOT alter what the client says: DO NOT translate the complaint in any way, such as "check skin" or "itches". You should attempt to clarify the complaint with questions such as:
    • How long has this been going on?
    • Has your pet ever had this problem before?
    • Do you notice that it is more of a problem at certain times of the day or after certain activities
  • Include annotations of vaccination status, reproductive status (spayed/neutered), diet, elimination abnormalities (bowels and urination), exercise level and any current medications the pet is on.

O (or E) = Objective Information - irrefutable information, actual observation, or tests performed.

  • Results of the physical examination, lab tests, or similar "hard data" information
  • Annotations of tests ordered with space left to record a summary when results are received.

A = Assessment of the Case - "what the client is told the problem is".

  • Dx is written if final diagnoses is known
  • TDx if diagnosis is almost certain, but is waiting for test results, etc.
  • DDx if there could be several diseases or conditions under consideration, the most likely choice first, the next most likely choice listed next, and so on.
  • Dx Open if the clinician has no diagnosis and needs further study or workup to complete
  • All records should be "closed" with a final diagnosis when the data is able to support one.

P = Plan - actions the clinician wants to take to resolve the problem or cure the disease.

Orders for medication (medication name, strength, dosage and refills if appropriate)

Client instructions,

  • Follow-up care instructions
  • Recheck instructions.
  • Each recommendation/instruction is written followed by a box.
  • If client accepts and it is executed, the VT initials box to signal task has been completed.
    • If the client refuses a recommendation a "W" is placed in the box = client Waived that item and does not want to pursue that course of treatment.
    • If the client accepts the recommendation but it is deferred "D" to a future date.
    • All deferred care should include a follow-up date to reschedule the recommended care

SOMR (another method) organizes the information based on how it was obtained.

  • Notes (history, exams, etc.) are combined chronologically together regardless of the problem. SOMR is more difficult to review specific cases at a later date.

Courtesy of Phil Seibert, CVT and Nanette Walker Smith, RVT, CVT

The Nerd Book
The VSPN Nerdbook was created by veterinary technicians and veterinary support staff for their colleagues. The Nerdbook provides information that veterinary technicians and support staff need in practice, but is not meant to contain everything. Procedures and policies vary among practices, so feel free to modify your Nerdbook fit your facility.
Volume One
Contributors
Introduction
Clinical Pathology
Critical Care - Triage
Emergency-Receptionist tips
Medical Calculations
You are hereMedical Records
Medical Terminology
Pharmacology
Physical Exam
Preventative Health
Radiology

Address (URL): http://www.vspn.org/Library/Misc/VSPN_M02369.htm

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