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Flashcards in Medical Records Deck (48)
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1

In nys records must be maintained for ____ years after the last visit

3

2

In NYS controlled substance logs must be maintained for _____ years

5

3

Can records and controlled sub logs be used in a court of law?

Yes, they are legal documents

4

If something is not written down, do you have record that it occurred?

No

5

Medical importance of good medical records

Prior history helpful when a problem recurs or related one develops
Clarity for clinic staff and clients to ensure good care

6

Who owns the medical records

The practice NOT the owner

7

The practice must provide a copy of medical records upon the owners

Written and signed request

8

Before releasing med records to another party, the practice must

Obtain the owners signed request

9

When the client changes vets, it is advisable to mail a copy of the record with

A cover letter (clients written and signed permission)

10

If animal has a reportable disease

Regulatory agencies must be notified with or without owners permission

11

Where to notify of reportable diseases

USDA
CDC
DOH or public health

12

Do you need permission from client to release records if they have been subpoenaed (summoner) in court

No

13

If an animal bites a human

Rabies vaccination history may be provided upon request to
Public health d
The bite victims physician
Animal control

14

If an animal bites another animal

Rabies vaccination history may be provided (upon request) to
The other animals vet
Animal control

15

Exceptions to record release rules

Reportable diseases
Subpoenaed in court
Animal bites human or other animal

16

Every entry in records should be

Written in black ink or typed
Date and time of every entry
Initial and credentials for every entry

17

Errors in a record should be

Readable, crossed out w single line, initialed

18

Patient record should include what ab the client

Name & spouses name
Address
Employment
# at home work cell and fax
Email

19

Patient record should include what info ab patient

Name
Case or record #
Signalment
Vx, Hx, PE, WNL or N, Dx, Tx, Sx, Rx, MAOR
Progress notes

20

Signalment

Detailed description for purposes of identification

21

Signalment includes

Species, breed, color and markings, microchip # or tat #
Dob (write est. if estimated)
Sex and reproductive status

22

Sex and reproductive status
M
F
M(N) or M/N
F(S) or F/S

Male
Female
Neutered male
Spayed female

23

Are female reproductive status part of signalment
Why or why not

No because they change
(Stage of estrus, pregnancy, lactation)

24

Every page of record should

Identify patient it belongs to (labels)

25

Vx Hx
Dx
Tx
Sx
Rx

Vaccination history
Diagnostic
Treatment
Surgical
Medications

26

MAOR
PE

Medication administration order record- table to record treatments, feedings, waste elimination, etc at specific times when hospitalized
Physical exam

27

Informed consent

Forms signed by clients saying that they have been sufficiently educated ab procedures (risks, prognosis, cost)
And
Client consents to the procedures and agrees to the cost

28

Medical record format: conventional (source oriented) (SOVMR)

Info is entered as it occurs

29

Medical record format: problem oriented (POVMR)

List of problems identified

30

POVMR master problems list

Diagnosed problems over animals lifetime