Medical Records 2

Medical Records 2Medical Records 2

Chapter 33Chapter 33

Paper/paperless/paper lightPaper/paperless/paper light

Traditionally medical records were all Traditionally medical records were all manually transcribed in the patient filemanually transcribed in the patient file

As practices have become more As practices have become more computerized and computer programs computerized and computer programs more sophisticated, practices have more sophisticated, practices have followed human medicine and are followed human medicine and are capturing more data in the medical capturing more data in the medical record without the use of paper files record without the use of paper files


Paperless applies to a practice that Paperless applies to a practice that manages all of its information on one manages all of its information on one computer systemcomputer system

Currently, most computerized Currently, most computerized practices are considered to be practices are considered to be paper paper light (lite)light (lite) since they still generate since they still generate tons of information which is not tons of information which is not stored in the computerstored in the computer


Examples of this are:Examples of this are:– RadiographsRadiographs– Consent formsConsent forms– FaxesFaxes– Consent formsConsent forms– New client/patient registration formsNew client/patient registration forms– Referral lettersReferral letters– All the practice logsAll the practice logs– Medical records from other practicesMedical records from other practices


With the advent of better more With the advent of better more affordable technology:affordable technology:

– like scannerslike scanners– CD-ROM technologyCD-ROM technology– signature capture signature capture

We can become more paperlessWe can become more paperless


Electronic media storage is safer than Electronic media storage is safer than printed media storageprinted media storage

It must be backed up and stored off siteIt must be backed up and stored off site

CDs can store thousands of documentsCDs can store thousands of documents

On line external site back can store On line external site back can store unlimited amounts of informationunlimited amounts of information


Legalities of computerized record Legalities of computerized record storagestorage

– To date, no paperless case has gone to To date, no paperless case has gone to court, so it has not been testedcourt, so it has not been tested

– Medical records must be protected from Medical records must be protected from alteration after the factalteration after the fact

– Proof of electronic medical record security Proof of electronic medical record security can be provided by having the backups kept can be provided by having the backups kept at an off site data storage facility. at an off site data storage facility.


A comparison can then be made by A comparison can then be made by the court to ensure both copies match the court to ensure both copies match which would ensure that the which would ensure that the information contained in the medical information contained in the medical record has not been altered and record has not been altered and corruptedcorrupted

In any system, all entries must be In any system, all entries must be initialed by the person making them initialed by the person making them

All of the new technology costs the All of the new technology costs the practice large sums of money initially, but practice large sums of money initially, but in the long run it provides a great return in the long run it provides a great return on investmenton investment

Current technology includesCurrent technology includes– Digital camerasDigital cameras– Flatbed scannersFlatbed scanners– Digital radiologyDigital radiology– Computerized digital otoscope/endoscopeComputerized digital otoscope/endoscope– Digital ultrasoundDigital ultrasound

formsforms

Top sheet client/patient informationTop sheet client/patient information

formsforms

Sticker sheets (2)Sticker sheets (2)

formsforms

Second sheetsSecond sheets

SOAP formatSOAP format– SubjectiveSubjective– ObjectiveObjective– AssessmentAssessment– PlanPlan

S = the way the patient appears to S = the way the patient appears to the casual observerthe casual observer

O = physiological dataO = physiological data– TPRTPR– vomiting/defecation/urinationvomiting/defecation/urination– Lab work resultsLab work results

Usually done by the technicianUsually done by the technician

A = the veterinarian would record A = the veterinarian would record the status of the patient. the status of the patient. – Ie. Post surgical no recovery issuesIe. Post surgical no recovery issues– Ie. PU/PDIe. PU/PD

P = the course of action that will be taken P = the course of action that will be taken that day as per the veterinarianthat day as per the veterinarian

formsforms

Pet report cardPet report card

Dermatology questionnaireDermatology questionnaire

In hospital boarding medication In hospital boarding medication sheetsheet

Status of admitted patientsStatus of admitted patients

Forms*Forms*

Post operative checklistPost operative checklist

Pain managementPain management

formsforms

Informed consentInformed consent

Discharge instructionsDischarge instructions

EstimateEstimate

euthanasiaeuthanasia

Medical recordsMedical records

Signalment – the first information you Signalment – the first information you receive from the owner. It includes:receive from the owner. It includes:– AgeAge– BreedBreed– SexSex– SpeciesSpecies

Of the patientOf the patient

It is usually collected along with the client It is usually collected along with the client information by the receptionist information by the receptionist

Medical Record Medical Record MaintenanceMaintenance

Active patient medical records covering a 3 year Active patient medical records covering a 3 year period are maintained in the primary medical period are maintained in the primary medical records collectionrecords collection

Records that are inactive 4 years or more are Records that are inactive 4 years or more are moved to storage that is easily accessiblemoved to storage that is easily accessible

Inactive records that are 8 years old or older can Inactive records that are 8 years old or older can be taken from storage and shreddedbe taken from storage and shredded

Deceased patient records must be treated the Deceased patient records must be treated the same waysame way

Medical Record OwnershipMedical Record Ownership

Medical records along with Medical records along with radiographs, etc are the property of radiographs, etc are the property of the veterinary practicethe veterinary practice

Owners may obtain a copy of their Owners may obtain a copy of their records upon request. (it can’t be records upon request. (it can’t be held if there is money due)held if there is money due)

A fee can be charged for the copiesA fee can be charged for the copies

Remember there are regulations Remember there are regulations regarding release of medical recordsregarding release of medical records

Medical LogsMedical Logs

LabLab AnesthesiaAnesthesia SurgerySurgery RadiologyRadiology Adverse reactionsAdverse reactions Sentinel eventsSentinel events OSHA trainingOSHA training Controlled substancesControlled substances

Health & Medicine

Medical Records 2