Medical Records

10,288 views

Published on

Published in: Health & Medicine, Business
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
10,288
On SlideShare
0
From Embeds
0
Number of Embeds
274
Actions
Shares
0
Downloads
413
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Medical Records

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

×