Vet Assisting Obj. 1.02 - Medical Records

Which is most accurate when describing the medical records of animals?

• Records are considered public information since only human medical records are confidential.

• Records may be shared with other clients who have animals with similar symptoms.

• Records may be shared with anyone associated with the veterinary practice.

• Records may be shared for veterinary care with the client's approval.

How long are many states required to keep medical records?

• 3 years

• 5 years

• 7 years

• 10 years

Which provides a chronological log for each time the patient is seen and treatment is completed?

• Confidentiality statement

• Radiology report

• Progress notes

• Anesthesia report

A veterinary assistant records notes in a medical record using the acronym SOAP as a guide. The notes for "P" would most likely include information about the:

• pedigree of the animal.

• potential of the animal.

• history of the animal's treatment.

• treatment plan for the animal.

The consent form is used to:

• retain confidentiality.

• identify to the client all procedures and prices incurred.

• identify the client's legal rights.

• retain the animal until payment is received.

When an error is made while recording in a medical record, one should:

• tear out that portion of the record and remove it from the file.

• place a single line through the error, initial it, and follow with correct information.

• hide the error with a dark marker like a sharpie and pretend it didn't happen.

• erase the error as much as possible, and then use "white-out" to cover what would not erase.

When should a cage card be used?

• Only when boarding an animal

• Only when 2 animals look alike

• Anytime an animal is left at the hospital

• At the owner's request

The first and most noticeable part of the medical record should be:

• client and patient information sheet.

• price list of all medical procedures available.

• progress notes.

• lab reports.

What part of the SOAP acronym represents the animal's temperature and heart rate?

• Subjective

• Objective

• Assessment

• Plan

The acronym VCPR establishes the following criteria:

• veterinarian does not assume responsibility for the patient's health.

• veterinarian does not claim to have sufficient knowledge of animal species.

• veterinarian may treat patient regardless of client wishes.

• veterinarian can make judgments regarding health, diagnosis, and treatment.