WorksheetsVet Assisting Obj. 1.02 - Medical Records
Total questions: 12
Worksheet time: 6mins
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.
A rabies certificate is issued:
before the pet has received its rabies vaccine.
after all puppy vaccines are given.
after the pet has received its rabies vaccine.
only when requested.
Information on the veterinary medical record should be recorded in:
red ink.
pencil.
purple ink.
black ink.
