Chapter 2: Medical Records

Study Guide

Objectives

Upon completion of this chapter, the reader should be able to:

  • Identify the various forms included in the medical record.
  • Properly create and label veterinary medical records.
  • Demonstrate how to record the information in the medical record.
  • Properly locate, file, and re-file medical records.
  • Discuss the importance of the legal requirements of the veterinary medical record.

Chapter Summary

All veterinary assistants are required to have a basic knowledge and understanding of veterinary medical record keeping. Medical records are used to summarize a patient’s history. Medical records are legal documents that allow veterinarians and the veterinary health care teamto properly care for each patient that is seen at the facility and as a means of communicating information to each other. A patient’s medical records tell the history of the patient in a diary-like script each time an animal visits the facility. It is important that every member of the veterinary health care team learn to accurately record information in the medical record. Medical records are a vital tool for every veterinarian and they rely on their staff members to properly assemble, record, and maintain medical records. Medical records are legal documents and valuable tools in the veterinary facility. The veterinarian and health care team rely on medical records to provide a history of each patient. This includes proper labeling, information, forms, and accurate notations. It is important to record everything and be accurate and neat!

Study List

  1. Properly assemble the medical record.
  2. Explain medical recording dos and don’ts.
  3. Describe the VCPR relationship.
  4. Discuss the importance of legal responsibility of veterinary medical records.
  5. Identify client information.
  6. Identify patient information.
  7. Identify and complete the master problem list.
  8. Identify and complete progress notes form.
  9. Identify and complete SOAP format.
  10. Complete cage cards.
  11. Complete any required logs, such as anesthesia, medication, or vaccination.
  12. Complete vaccine forms.
  13. Complete rabies certificate.
  14. Complete health certificate.
  15. Complete neuter certificate.
  16. Discuss consent forms/client waivers.
  17. File using the alphabetical filing method.

Competency Skills Mastery

You should be able to demonstrate the following skills competencies for this chapter:

  • Medical record assembly
  • Filing medical records

-Alphabetical method

-Numerical method

-Files for appointments

Resources and Bibliography

Kehn, Robert. Veterinary Office Practices. CliftonPark: Delmar Cengage Learning, 2004.

Robinson, Gordon W. Standard Abbreviations for Veterinary Medical Records. Philadelphia: AAHA, 2000.

Romich, Janet A. An Illustrated Guide to Veterinary Medical Terminology. 3rd ed. CliftonPark: Delmar Cengage Learning, 2008.