04 - Medical Records

Review:
What did we learn last class?

Drag and Drop

If you didn't write it down in the medical record, it ​

Placeholder

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Placeholder

.

Drag these tiles and drop them in the correct blank above

didn't

matter

is

ok

doesn't

cannot

happen

count

Poll

If you have worked or volunteered in a medical office, what type of record system did they use?

• Paper only.

• Paper and electronic.

• Electronic only.

• N/A

Multiple Choice

How should you correct a mistake on a medical record?

Multiple Choice

What is NOT something we must do in medical records?

• Leave large blanks

• Be clear

• Be concise

• Be accurate

Multiple Choice

The original medical records are the property of ....

• the hospital
• the insurance company
• the government
• the patient

Multiple Choice

How are Source Orientated Medical Records organized?

• Organized based on the alphabetical order of the patient's last name

• Organized based on the patient's personal information

• Organized based on the source of the information, such as veterinarian's notes, lab reports, and imaging results.

Multiple Choice

How are Problem-Orientated Medical Records organized?

• By organizing the records alphabetically
• By arranging the records based on the patient's age
• By dividing the medical history into different sections based on the patient's problems or diagnoses.

Multiple Choice

In medical records, what is information a Database would store?

• Weather forecasts, sports scores, and stock market data
• Cooking recipes, travel itineraries, and fashion trends
• Traffic patterns, real estate listings, and movie reviews
• Client/patient information, medical history, medications, and lab results.

Multiple Choice

What is an example of something a Master Problem List or Working Problem List would contain?

• List of all the patient's active and inactive medical issues
• List of all the patient's surgical procedures
• List of all the patient's medications

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Multiple Choice

What is the most important diagnostic tool?

• Blood pressure measurement
• X-ray imaging
• Genetic testing
• The physical exam

Multiple Select

Why do we SOAP?
More than one answer may be correct!

• To organize information

• Evaluates critical thinking

• Provides effective communication

• To wash our hands

• Reduces mistakes or redundancy

Subjective Data

All non-measurable data:
Colour, descriptive terms, degree of lameness, signs of pain, hydration status, ***history from owner***, etc

Multiple Choice

What is an example of "subjective" in formation in a medical record?

• Patient's reported pain level
• Medical test results
• Prescribed medication
• Doctor's diagnosis

Objective Data

Data that can be measured or quantified, such as:
temperature, heart rate, respiratory rate, weight, exact amount of urine passed, previous test results, CRT, etc.

Multiple Choice

Blood test results are an example of Objective data.

• True

• False

Multiple Choice

The patient passed 20.2 grams of fecal pellets.

• Subjective

• Objective

Multiple Choice

The owner notes the patient has urinated 5 times in the bathtub.

• Subjective

• Objective

Assessments

The "A" part of the SOAP.
Used the "S" and "O" part of the SOAP to form a list of patient responses/conditions.

Conclusions regarding the patient's response to a physical or emotional challenge.
We prioritize the most life-sustaining needs first.

Technician's

Differential Diagnosis
(a list of potential diagnosis to the presenting complaint after reviewing the Subjective and Objective data.)

Veterinarian's

Assessments

Multiple Choice

Restricted Airway

• Subjective

• Objective

• Assessment

• Plan

Plan

The "P" part of the SOAP
This is the intervention we will undertake for the assessments we have listed.
A doctor's plan will differ from a technician's plan.

Multiple Choice

Can this be part of a technician's plan?
"Neuter and administer vaccines."

• Yes

• No

Multiple Choice

Can this be part of a technician's plan?

"Provide comfortable bedding and re-position patient every 2 hours."

• Yes

• No

Open Ended

What should be included on a Kennel / Cage Card?

Multiple Choice

What should be on a veterinary consent form?

• Number of pets owned by the client, veterinarian's favorite color, cost estimate, and signature of the owner.

• Owner's name, contact information, pet's name, description of the procedure or treatment, risks and benefits, cost estimate, and signature of the owner.

• Owner's name and driver's license, pet's name and favorite food, risk of the procedure, preferred colour, and horoscope.

Multiple Choice

What does "Layman's terms" mean?

• Explaining something in a simple and understandable way, without using technical jargon or complex language.
• Referring to a person who is not a professional in a certain field
• Using highly technical language to explain a concept
• Describing something in a way that only experts can understand

Multiple Choice

When should we return a patient to their owner?

• Before the discharge

• After the discharge

• As the client is driving away

• After the intake

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Multiple Select

How should we maintain medical records?

Select all that apply!

• Confirm contact details each time client comes in.

• Put the heaviest records on the bottom of the filing cabinet.

• Ask about pets not seen in a while

• Record information as soon as possible.

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Review!

Multiple Select

Which of the following are things to keep in mind for writing in medical records?

• No liquid paper.

• Write in pen (blue or black).

• Sign / initial what you've written.

• Write legibly.

• Written in yellow or orange ink.

Multiple Choice

How long should medical records be kept in New Brunswick?

• At least 2 years after the last patient contact

• Indefinitely.

• At least 5 years after the last patient contact
• At least 10 years after the last patient contact.

Multiple Choice

The cat's temperature was 40.1°C

• Subjective

• Objective

• Assessment

• Plan

Multiple Choice

The cat urinated a large amount in the litter box.

• Subjective

• Objective

• Assessment

• Plan

Multiple Choice

Owner declined treatment.

• Subjective

• Objective

• Assesment

• Plan

Draw

Draw an example of the proper way to correct this mistake on a medical record.

It is very important that you will be present in class, as we will have 2 assignments on this. The first one we will do together in class.

​Bring pens +/- highlighers.

Next week we will be writing a mock medical record / surgery story.