Medical Records 2


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Medical Records 2

  1. 1. Medical Records 2 Chapter 33
  2. 2. Paper/paperless/paper light <ul><li>Traditionally medical records were all manually transcribed in the patient file </li></ul><ul><li>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 </li></ul>
  3. 3. Paper/paperless/paper light <ul><li>Paperless applies to a practice that manages all of its information on one computer system </li></ul><ul><li>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 </li></ul>
  4. 4. Paper/paperless/paper light <ul><li>Examples of this are: </li></ul><ul><ul><li>Radiographs </li></ul></ul><ul><ul><li>Consent forms </li></ul></ul><ul><ul><li>Faxes </li></ul></ul><ul><ul><li>Consent forms </li></ul></ul><ul><ul><li>New client/patient registration forms </li></ul></ul><ul><ul><li>Referral letters </li></ul></ul><ul><ul><li>All the practice logs </li></ul></ul><ul><ul><li>Medical records from other practices </li></ul></ul>
  5. 5. Paper/paperless/paper light <ul><li>With the advent of better more affordable technology: </li></ul><ul><ul><li>like scanners </li></ul></ul><ul><ul><li>CD-ROM technology </li></ul></ul><ul><ul><li>signature capture </li></ul></ul><ul><ul><li>We can become more paperless </li></ul></ul>
  6. 6. Paper/paperless/paper light <ul><li>Electronic media storage is safer than printed media storage </li></ul><ul><li>It must be backed up and stored off site </li></ul><ul><li>CDs can store thousands of documents </li></ul><ul><li>On line external site back can store unlimited amounts of information </li></ul>
  7. 7. Paper/paperless/paper light <ul><li>Legalities of computerized record storage </li></ul><ul><ul><li>To date, no paperless case has gone to court, so it has not been tested </li></ul></ul><ul><ul><li>Medical records must be protected from alteration after the fact </li></ul></ul><ul><ul><li>Proof of electronic medical record security can be provided by having the backups kept at an off site data storage facility. </li></ul></ul>
  8. 8. Paper/paperless/paper light <ul><li>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 </li></ul><ul><li>In any system, all entries must be initialed by the person making them </li></ul>
  9. 9. <ul><li>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 </li></ul><ul><li>Current technology includes </li></ul><ul><ul><li>Digital cameras </li></ul></ul><ul><ul><li>Flatbed scanners </li></ul></ul><ul><ul><li>Digital radiology </li></ul></ul><ul><ul><li>Computerized digital otoscope/endoscope </li></ul></ul><ul><ul><li>Digital ultrasound </li></ul></ul>
  10. 10. forms <ul><li>Top sheet client/patient information </li></ul>
  11. 11. forms <ul><li>Sticker sheets (2) </li></ul>
  12. 12. forms <ul><li>Second sheets </li></ul><ul><li>SOAP format </li></ul><ul><ul><li>Subjective </li></ul></ul><ul><ul><li>Objective </li></ul></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><li>Plan </li></ul></ul>
  13. 13. <ul><li>S = the way the patient appears to the casual observer </li></ul><ul><li>O = physiological data </li></ul><ul><ul><li>TPR </li></ul></ul><ul><ul><li>vomiting/defecation/urination </li></ul></ul><ul><ul><li>Lab work results </li></ul></ul><ul><ul><li>Usually done by the technician </li></ul></ul>
  14. 14. <ul><li>A = the veterinarian would record the status of the patient. </li></ul><ul><ul><li>Ie. Post surgical no recovery issues </li></ul></ul><ul><ul><li>Ie. PU/PD </li></ul></ul><ul><ul><li>P = the course of action that will be taken that day as per the veterinarian </li></ul></ul>
  15. 15. forms <ul><li>Pet report card </li></ul><ul><li>Dermatology questionnaire </li></ul><ul><li>In hospital boarding medication sheet </li></ul><ul><li>Status of admitted patients </li></ul>
  16. 16. Forms* <ul><li>Post operative checklist </li></ul><ul><li>Pain management </li></ul>
  17. 17. forms <ul><li>Informed consent </li></ul><ul><li>Discharge instructions </li></ul><ul><li>Estimate </li></ul><ul><li>euthanasia </li></ul>
  18. 18. Medical records <ul><li>Signalment – the first information you receive from the owner. It includes: </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Breed </li></ul></ul><ul><ul><li>Sex </li></ul></ul><ul><ul><li>Species </li></ul></ul><ul><ul><li>Of the patient </li></ul></ul><ul><ul><li>It is usually collected along with the client information by the receptionist </li></ul></ul>
  19. 19. Medical Record Maintenance <ul><li>Active patient medical records covering a 3 year period are maintained in the primary medical records collection </li></ul><ul><li>Records that are inactive 4 years or more are moved to storage that is easily accessible </li></ul><ul><li>Inactive records that are 8 years old or older can be taken from storage and shredded </li></ul><ul><li>Deceased patient records must be treated the same way </li></ul>
  20. 20. Medical Record Ownership <ul><li>Medical records along with radiographs, etc are the property of the veterinary practice </li></ul><ul><li>Owners may obtain a copy of their records upon request. (it can’t be held if there is money due) </li></ul><ul><li>A fee can be charged for the copies </li></ul>
  21. 21. <ul><li>Remember there are regulations regarding release of medical records </li></ul>
  22. 22. Medical Logs <ul><li>Lab </li></ul><ul><li>Anesthesia </li></ul><ul><li>Surgery </li></ul><ul><li>Radiology </li></ul><ul><li>Adverse reactions </li></ul><ul><li>Sentinel events </li></ul><ul><li>OSHA training </li></ul><ul><li>Controlled substances </li></ul>