Mark Pet Health Record Made Easy

E signature veterinary hospital treatment sheet

this is chapter 3 mckernan's book it's veterinary medical records again we have learning objectives for each chapter and i just pay attention to those bolded words to help you understand what we're going to be focusing on today the purposes of the medical record the primary purpose is to support excellent medical care if we don't document what is being done then we can't follow the pet to make sure that things that the pet is responding normally so it documents both procedures and communication between the people doing the procedures as well as with the client so that's the primary purpose excellent medical care procedures and communication the secondary purpose is to support business activities like getting payment for what you're doing supporting legal activities supporting research so if we can gather data about the pets that we treat we can learn things about the diseases about preventive care about vaccine reactions etc veterinary client patient relationship this is part of the medical and legal requirements we have to have a veterinary client patient relationship that's a vcpr and that exists when the veterinary veterinarian takes responsibility for clinical judgments and the client agrees to comply the veterinarian must be personally familiar with the keeping and care of the animal and the veterinarian has to be readily available available or has arranged for emergency care and follow-up in cases of adverse reactions or treatment failure that can simply mean that you have an outgoing message on your clinic phone that states that there is emergency care available at a local emergency veterinary hospital and you can give the number for that or the veterinarian might leave their emergency phone for the client so that there's follow-up care for that pet you always have to ask do you have a vcpr with this pet if you don't have a vcpr with a pet or with a client that means that you are not going to be able to provide care and that includes prescribing medications for the pet there's an importance of informed consent if you don't inform and educate your clients prior to treatment and set those ex prior to treatment then you're going to have an unhappy client so that means that we have to have the malady so identify the illness and the symptoms have a potential diagnosis and a potential prognosis and some of these things we we may need to decide as we go along so we'll come back to it that goes with evaluation reevaluation but we have to keep the clients communicated with and educated as we go through it we need to talk about all the treatment options all the follow-up care and all the emergency plans and a justification for the treatment costs don't justify too much when you justify too much for treatment costs you you make the treatment less valuable to the client you have a treatment it costs this much period we have things that we use in the in the procedure we have people that we have educated and trained for this procedure and this is what it costs for this procedure there's no there's no need for justification the more you justify the less valuable it becomes to the client you need to document this informed consent you have to document all of the education that you did with the client prior to the consent you don't have to be super detailed if you do it the same way every time if you have a written sheet you can just say gave them a handout on this written sheet as long as you have some sort of documentation so we always want to have them sign an authorization form that says that we can treat the pet and that if there's a an emergency and we can't get a hold of them that we have their consent to treat this the consenters or the signers of this form must be 18 years old or older and sometimes you just have to ask that question having a fee estimation form will will let the client know what you anticipate is going to be happening it will help you talk about the costs and will help them to expect to know that your expectation is that they're going to pay for the procedure pay for the treatment when they pick the pet up you need to set those expectations properly and because it prevents confusion and conflict later on i don't mind knowing that i have a four hundred dollar car care bill coming up if i know ahead of time if i walk into the mechanic and he said oh yeah i didn't call you but it's going to be about 400 that's going to make me a little bit more upset because i haven't been able to plan for it it's not in my head ready to go so set those expectations early documentation this protects against litigation or going to court and complaints uh you want to write it down in black ink or blue ink and and or type it a lot of these go actually into a computer these days you want to make sure all documents are signed including credentials your credentials your veterinarian's credentials the date time and e-file if you have a tendency to just initial your entries then you're going to have to have a log book that has your initials and your full name written out beside it so that anybody who looks at it will know who signed off on it you need to be able to write legibly this is very difficult for some of us veterinarians and so that's why i really like computerized systems but it's really important that people are able to read what you're writing in the medical document any tampering or inaccuracies cast out on the entire record the integrity of the entire record so if you have something that you made a mistake on it's not a big deal just put a line through it and say error and then sign and date it people need to know that you know that there's an error if you don't catch it that's what puts the doubt ownership and release of medical information the record is owned by the practice not the client clients can have copies and they should be able to demand copies that's it's their pet they should have that information um but they you have to have an authorization from the client uh a signed authorization is best if you can get an authorization and have two witnesses verbally that's fine too if we have if we have something going directly to a another veterinarian that may be an exception you can mail or email copies with a cover letter the copies uh may have to be charged to the client and i have this coming up every so often just to remind you if you didn't document it you didn't do it so document document document there are two formats of veterinary medical records one is source oriented the other is problem oriented if you are using a source oriented medical record it is a shorter record and it doesn't contain as much details problem oriented is based on the problem it's much easier to find the details there is also a ability to do a combination of a source oriented with a problem oriented and we'll talk about the combination again if you didn't document it you didn't do it okay that includes talking to clients because clients will call up and say well they never told me that my dog couldn't run after surgery well if you didn't put in the medical record then you didn't do it even if you said it five times the source oriented veterinary medical record it looks kind of like this it's a it's basically usually a card or a piece of paper may have lines on it may not and it's categorized by date so on 10 13 this dog had a splenic mass and some renal failure on 10 19 the owner wanted an appointment to speak to b who i assume is the doctor on 10 20 owner decline decided to cancel the dog's not doing well so that's not a lot of information it it's a little bit of information and if we wanted to find out what the problem was we'd have to know exactly what date that splenic mass was found in order to go back and find it so usually we have these these source oriented veterinary veterinary available so we'll have little cards that we use the information from the sources and we are the sources or the doctor or different veterinary texts through the sources they're all entered in chronological order by office visit or hospital stay it's quick and easy to write these but it lacks a lot of detailed documentation but if you don't document it you don't do it problem oriented veterinary medical records are more complete they we use these with folder type medical records uh they support a very logical and organized approach to clinical medicine it goes through complicated medical cases one problem at a time so you'll have a pro master problem list with all the problems the animals ever had and that works as your index it's going to include things like a physical exam form which is what this is it'll include radiographs it'll include um it'll in include biopsy results it'll include everything and it'll be in the each mat each problem will have its own section but if you didn't document it you didn't do it some components like i said there are lots of things that are included in client and patient information history physical exam findings pertinent test results master problem list and the working problem list we always we don't always know what's happening with a pet when they first come in so we have a working problem list and then we when we figure out what it is it goes to the master problem progress notes assessment and plan treatment related forms and then case summary and discharge instructions so everything is included in it for the previous medical history we want the animals birthplace and date their previous preventive medicine programs vaccinations or immunizations parasite control dental and ear care procedures such as preventive maintenance stuff their behavior is it normal or abnormal or is this a dog or a cat that we have to be cautious of their environment where do they live uh how many pets do they live with any known allergies or reactions and previous medical or surgical conditions the recent medical history is what are they coming in for today what's their presenting complaint and what are the circumstances surrounding that complaint we want to know when we're getting this history when was the last time the animal was normal what are the frequency of the episodes that are bringing the animal in or is it something that has been constantly getting worse what are the current medications any previous treatment efforts for this complaint the owner's concerns and their comments their current diet and any information from a referring or previous veterinarian this recent medical history all comes as subjective information it's all coming in from the client or from previous history and we call that subjective information here's an example of a history form that's an electronic history form and the electronic medical records are terrific because not only can we do a problem-oriented veterinary medical record we can also do source oriented so we can do searches for the date that we treated them for certain things or how were they feeling on this date and we can do searches for uh data within this system searching for all animals that have ever had a splenectomy uh where we take the spleen out and then look at the that data in there or when was this last animal in for a dental so there are a lot of different things that are great about using an electronic form this is an example of a history form on paper uh where you're getting gathering all the pertinent information it's nice to have forms because then you don't forget infirm to ask certain things and within this form we have statement of ownership and consent as as well as the payment choice so we're asking them think about payment as they bring the pet in setting those expectations physical examination and pertinent forms the physical examination is very important uh diagnostic procedures it's the first thing that we have to do in order to understand what's going on with a pet obviously they don't speak with it speak to us so we have to use our hands our eyes our ears our nose in order to decide and determine what's going on we may also have to do a variety of diagnostic tests and and then file those tests physical examination and laboratory diagnostic tests those are things that are objective information those are facts they are data those are objective information our master problem list this is the defining part of the problem-oriented veterinary medical record it's the index to the patient's medical history and it includes major medical disorders experienced by the patient during its lifetime so our master problem list is our diagnosis our final diagnosis of the problem for which they came in and this is an assessment and so this is part of our working problem list can be a part of the assessment our master problem list is definitely an assessment of what the what's going on with a patient here's an example of a working problem list and we use this to work through current problems when an animal comes in with problem number one depression and lethargy it could be a variety of things problem number two is that they have pale yellow mucous membranes pile problem number three on this date is mild tachycardia so we're going to put those three things together as our symptoms and where we are going to um we are going to do our physical exam and our diagnostic tests and we're going to work on a master problem um on 7 20 and 7 20 uh we had anemia and ictrus and 724 we have a master problem list a master problem this tells us that all of these things with our diagnostic tests led us to believe this was autoimmune hemolytic anemia which is a disease so that is going to be our that's going to move to our master problem list and that is an assessment so when we are writing these records up we tend to write it in the form of a soap note soap is subjective which is that patient history and the client complaint objective which is the data and the facts assessment which is the diagnosis or the working problem list and the diagnosis can also be your technical assessments and the plan the plan is what are you planning to do in each step of the way you may plan to do a physical examination and laboratory tests you need to write that in the plan you're going to write the results in the objective after you get them but your plan starts with i'm going to do laboratory tests so technician soap notes are subjective objective assessment and plan the assessment is going to deal with the hierarchy of physiologic needs so if they come in and they're having trouble breathing that is that's a dyspnea and that is a very strong physiologic need we need to deal with that too that first it also assessment can assign prioritization numbers and that fits within our practice model whatever however we assess it and then our plan includes those notations um all of the things that we're planning on doing and also it includes our client education because they are part of the plan and again if you didn't document you didn't do it so are subjective you usually write those as a veterinary technician and that's kind of how the animal appears from casual observation so that's the owner's observation and your observation the objective you start to do the veterinary uh or as the technician you start to do the objective um getting the physiologic data such as temperature pulse respiration if there's vomit urination defecation especially within the exam room any laboratory data such as blood surgical site the catheter placement swelling and drainage all that data goes in the objective the assessment is performed mostly by the veterinarian although the veterinary technician there are there's a box in your uh chapter in in chapter three and actually it's explained even better in chapter 19 that helps you to to have very specific words to describe the symptoms uh that you're seeing in really it's so you have your own technical assessments that i do encourage you to do and will encourage you to do it helps us to determine the overall status of the patient it helps us to develop that tentative diagnosis the plan is presented by the veterinarian and that's the course of your action for the day and for recovery of the pet so i'm going to have you do this activity it's to write the following information in a soap format this is just going to get you started on how to write a soap note so you're going to take this information you're going to decide which of this information is subjective which is objective which is an assessment and which is your plan okay and once you've done this i actually want you to type it out you can write it down if you like and scan it in but it's best if you can type it out because then you can adjust it as i give you notes and then i want you to upload that document into the dropbox that i have available for you you can look at once you're done your uh once you've uploaded that to a drop box a an example will appear and you can take a look at it and see what you did right what you may have done differently there are a lot of different ways to write soap notes but they're very clear delineations between what is subjective what is objective what is assessment and what is planned that's what we're really looking for to make sure that you get those in the right areas look at those things and ask questions all right we're going to talk about maors these are medication administration order records or award treatment sheets so this would be something that you might find at the bottom of at the base of somebody's bed in a hospital so somebody could come in or now it's a computerized but somebody can go in and look at okay what are we doing with this patient today or this week okay so it's the summary of the patient's hospital management what their treatments are the dates the times the doses the roots any cautions what our short-term goal is what the patient name is all that stuff so that we can make sure we're treating the right pet and then a signature chart so we know that know who's providing the care um it's a at a glance summary of the patient management during their hospitalization and there's a couple ways to do it we can do it on the cage but often we have a white board available so that we can see what everybody needs to have done at any given time we check those things off as we get them done additionally it could be done as a computerized so everything could be put in the computer and we can check them off as we go through each treatment plan in order to make sure we're treating the right patient we need to identify the patient appropriately i don't know if you've heard but recently there was a story of a pet there's been a couple stories actually of a pet who've been accidentally euthanized it was the wrong pet given medication that euthanized the pet so identify finding pets is really important we also don't want to give them the wrong information so just as if you were going to the hospital they check your name every time they give you a medication or ask you questions this is what you're going to need to do with those pets so we will have an identification card on the the cage where they're staying we may have a little sticker that says caution if we have to be careful with that pet and then we also want to have a identification band on the the pet as well so both of those check both of those make sure the right patient is in the right cage and that you're treating the right pet we might store medication on the kennel although we don't always recommend this unless the patient is very quiet and isn't climbing on the kennel because otherwise this will get scattered everywhere even cage cards and medical notes might need to be stored elsewhere because a lot of patients will reach around and and tear that up discharge in summary forms we need to be very clear remember we're dealing with a public that doesn't always know what to do with their pet and even if they're a medical person like a nurse or a doctor they often make interesting decisions about what would be appropriate to do with their pet and so we want to be really clear with our discharge guidelines when we do it why we do it what we're doing and how we're doing it as a technician it's your job to demonstrate the technique review complications get their contact information give them contact information have a follow-up plan when are we going to see the patient again make sure they understand community resources if they need help we're not here for them what can they do mark the time of discharge who we discharged to how they transported the pet and all of the information that we give gave them if we have brochures or handouts that we regularly give we can store those in the computer and we can say gave them this handout and we'll know what we gave them and again if you didn't document it you didn't do it when we are managing paper medical records now a lot of clients clinics like i said have gone to computerized records which does make things easier at some point if electricity goes down your computer system goes down you may have to move to paper medical records so it's it's really helpful to have both systems they may not be going at the same time but to be able to move back and forth can be helpful um letter size folders uh for problem oriented medical records it's an eight by ten inch folder it holds that medical information usually tabs so we can put new things in there all the time with color-coded decals on the top tabs for easy filing and retrieval here's some examples of some folders and some different filing systems sometimes based on the year that they came in with their last name sometimes it's more complicated where we have them um uh categorized by year and uh last name a little bit differently and or they have a client number so filing systems there's alphabetic so each letter is assigned to different colors so you can kind of see based on color it's easier because you don't have a master list of clients i'll explain that in a minute that you have to cross-reference to but incorrectly spelled names can be misfiled and obviously employees have to know their alphabet the numeric filing system is one in which each client is assigned a unique number so you have a you have a number that is assigned to you as a client uh each digit in the number is assigned a different color and files are shelved from lowest to highest in numeric order so we spot that really easily but if we have a every client has a number then we have we can look up that client based on the number here's an example of what we're talking about a misfiling you can see these are color coded in ascending order you can see that this one is out of order so you can see that really easily file purging that's a lot of files if you have a lot of clients a lot of files to go through and if you have clients that don't come in for a while you may want to purge them so there is a process that a legal process that you have to go through and we go want to do a file purge at least once a year where primary records are those that are active for the last three years those are going to be stored within your main filing area we're going to put any records that have been inactive for more than four years four years or more i'm going to put those in storage things that have been active for more than eight years are going to be purged and shredded we do need to mark lost records that's really important to make record of lost records because that helps if we have an issue legally later on electronic records there are a lot of advantages to having electronic records fewer errors and misplaced documents greater efficiency and convenience you can read the doctor's writing that's helpful multiple individual access improved quality and legibility that's the doctor's writing thorough we can have templates and prompts that help us to make sure that we get everything documented scanning and importing key documents and images in directly into their records so that we don't have large x-ray files sticking out somewhere needs to be validated we do have to be careful of loss of medical records if they're electronic the best way to do that is to store it to save it constantly on-site and then also have an off-site location where we send the information a cloud basically where we send the information have it stored off site here's an example of a radiologist working mris or ct scans of brain but this is showing how we can pull some of these images directly into the medical record and pull them up anytime we have to review them logs logs are an important way to collect data as well these are continuously updated data that serve two purposes documentation for legal support and data for quick analysis and retrospectives so there are a couple of places where we're going to keep logs they may be departmental logs so for instance in surgery if we have a surgical log we can mark what surgery was done on what pet by whom and how long it took them and that's going to give us a quick indication of how people are doing through surgery what kind of surgeries we do every day and give us an idea of how to prepare for those appointments and surgical procedures drug reactions are an important thing to log as well because we need to maintain an understanding of drug reactions to see if there's a pattern so that we can communicate with a manufacturer unexpected deaths those are important to log because we need to track those as well that may be a legal issue and so we need to make sure we're on top of that medical waste logs are important and typically we have a medical waste service that actually keeps those logs for us and then a controlled substance log is equally important it's required by the dea that we keep a log of all materials all controlled substances in the amounts that we have the amounts that we bring in the amounts that we give the amounts that we throw away one additional log that we do have to take for legal reasons keep for legal reasons would be a radiology log where we keep track of what x-rays we're taking and who is taking those x-rays if you have an ambulatory practice an ambulatory practice is a practice that travels to the farm or to the to a house these are sometimes kept on carbonized sheets so they they take uh they write a medical record and they give a copy to the client and sometimes it it it works as an invoice as well so one copy is given to the client and one is taken back to the office and that information is then entered into the client's permanent record nowadays we're moving to laptops and notebooks so that we have wireless transmission or synchronization of those files here's some examples of some ambulatory systems here's an old vet truck old vet farm truck and and then here's a specialized system this is a a system where they're bringing in the information from the field and putting it into the computer system that's what we have on medical records some things i definitely want you to look into technical assessments i want you to look at those i'm going to be asking you about technical assessments at some point in the next couple of semesters and you need to know where to look for those so technical assessments take take a look at that need to understand what soap notes are and how to write them and you need to understand the differences between the different types of medical records if you have any other questions let me know when we meet in class