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Medical Records 2


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  • 1. Medical Records 2 Chapter 33
  • 2. Paper/paperless/paper light
    • Traditionally medical records were all manually transcribed in the patient file
    • As practices have become more computerized and computer programs more sophisticated, practices have followed human medicine and are capturing more data in the medical record without the use of paper files
  • 3. Paper/paperless/paper light
    • Paperless applies to a practice that manages all of its information on one computer system
    • Currently, most computerized practices are considered to be paper light (lite) since they still generate tons of information which is not stored in the computer
  • 4. Paper/paperless/paper light
    • Examples of this are:
      • Radiographs
      • Consent forms
      • Faxes
      • Consent forms
      • New client/patient registration forms
      • Referral letters
      • All the practice logs
      • Medical records from other practices
  • 5. Paper/paperless/paper light
    • With the advent of better more affordable technology:
      • like scanners
      • CD-ROM technology
      • signature capture
      • We can become more paperless
  • 6. Paper/paperless/paper light
    • Electronic media storage is safer than printed media storage
    • It must be backed up and stored off site
    • CDs can store thousands of documents
    • On line external site back can store unlimited amounts of information
  • 7. Paper/paperless/paper light
    • Legalities of computerized record storage
      • To date, no paperless case has gone to court, so it has not been tested
      • Medical records must be protected from alteration after the fact
      • Proof of electronic medical record security can be provided by having the backups kept at an off site data storage facility.
  • 8. Paper/paperless/paper light
    • A comparison can then be made by the court to ensure both copies match which would ensure that the information contained in the medical record has not been altered and corrupted
    • In any system, all entries must be initialed by the person making them
  • 9.
    • All of the new technology costs the practice large sums of money initially, but in the long run it provides a great return on investment
    • Current technology includes
      • Digital cameras
      • Flatbed scanners
      • Digital radiology
      • Computerized digital otoscope/endoscope
      • Digital ultrasound
  • 10. forms
    • Top sheet client/patient information
  • 11. forms
    • Sticker sheets (2)
  • 12. forms
    • Second sheets
    • SOAP format
      • Subjective
      • Objective
      • Assessment
      • Plan
  • 13.
    • S = the way the patient appears to the casual observer
    • O = physiological data
      • TPR
      • vomiting/defecation/urination
      • Lab work results
      • Usually done by the technician
  • 14.
    • A = the veterinarian would record the status of the patient.
      • Ie. Post surgical no recovery issues
      • Ie. PU/PD
      • P = the course of action that will be taken that day as per the veterinarian
  • 15. forms
    • Pet report card
    • Dermatology questionnaire
    • In hospital boarding medication sheet
    • Status of admitted patients
  • 16. Forms*
    • Post operative checklist
    • Pain management
  • 17. forms
    • Informed consent
    • Discharge instructions
    • Estimate
    • euthanasia
  • 18. Medical records
    • Signalment – the first information you receive from the owner. It includes:
      • Age
      • Breed
      • Sex
      • Species
      • Of the patient
      • It is usually collected along with the client information by the receptionist
  • 19. Medical Record Maintenance
    • Active patient medical records covering a 3 year period are maintained in the primary medical records collection
    • Records that are inactive 4 years or more are moved to storage that is easily accessible
    • Inactive records that are 8 years old or older can be taken from storage and shredded
    • Deceased patient records must be treated the same way
  • 20. Medical Record Ownership
    • Medical records along with radiographs, etc are the property of the veterinary practice
    • Owners may obtain a copy of their records upon request. (it can’t be held if there is money due)
    • A fee can be charged for the copies
  • 21.
    • Remember there are regulations regarding release of medical records
  • 22. Medical Logs
    • Lab
    • Anesthesia
    • Surgery
    • Radiology
    • Adverse reactions
    • Sentinel events
    • OSHA training
    • Controlled substances