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Medical Records

Medical Records






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    Medical Records Medical Records Presentation Transcript

    • Medical Records
      • One of the most important and complicated tasks for the hospital staff
      • Veterinary medical records include a wide range of forms and logs that document the treatment and care of patients
    • Medical Records
      • There are 2 major functions of the medical record
    • Medical Records
      • The primary purpose is to support the patients medical care by documenting:
        • Diagnostic procedures
        • Diagnoses
        • Prognoses
        • treatment
      • It supports excellent medical care by:
        • Aiding in identification of client and patient
        • It helps in generating an effective diagnostic and treatment plan
            • Physical exam findings
            • Diagnostic procedures and tests to be performed
            • Records the veterinarians differential diagnoses ideas
            • Documents patients responses to treatment
            • Supports continuity of care
      • It documents communication with the client
      • Assists in the generation of reminder postcards that help owners stay current with their preventative medical care
      • Aids interactions with the clients and their pets
    • Medical Records
      • The secondary purposes include evaluations of medical information for:
        • Business
        • Legal
        • Research
        • purposes
      • The medical record lists all the services rendered to the pet
      • It verifies services billed to the owner
      • It serves as legal evidence of the services received by the owner
      • It is also used to assess:
        • Staffing
        • Formulate income analysis
        • Help budget
        • Helps maintains inventory
        • Generates marketing strategy
        • Plays an important role in hospital accreditation
        • Helps assess compliance with standards of care
      • Medical records are used as a legal document in a court of law during litigation
      • It serves as evidence of procedures and treatments performed by providing specific dates and times
      • It is critical in defending against malpractice suits
    • St
      • It must be complete and accurate
      • In court, if it is not written and initialed, it has not been done
      • Insurance will require to decide whether to pay a claim
      • They are an important element in preparing case studies, research and presentations.
      • All patient information (name, etc) must be removed to maintain patient confidentiality
    • Types of Medical Records
      • There are 2 major types
      • Letter size folders
      • Pocket card files
      • Ambulatory large animal practices will use carbon forms and/or computers
      • There has been a large shift to laptop computers
      • Records are not always kept on individual animals but on the entire herd
      • Medical records are not subject to the same federal and state regulations as human medical records
      • The most widely used format is the problem-oriented veterinary medical record (POVMR)
    • POVMR
      • Is used in teaching hospitals
      • AAHA-accredited hospitals
      • Specialty/referral hospitals
      • Most private hospitals
    • POVMR
      • Commonly includes the following:
        • Client patient information
        • History
        • Physical exam
        • Master problem list and working problem list
        • Progress notes, assessment, and plan
        • Pertinent forms: surgery, anesthesia, radiography, laboratory reports
        • Case summary
        • Fee information
      • New client/patient form
      • Confirms a valid client/patient/doctor relationship
      • Has to have the finance charge information otherwise it can not be collected
      • Top Page Form
      • Second Page form
      • Paper/ Paperless/ Paperlite