Term
| How long does a clinic keep medical records? |
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Definition
| A minimum of four years after the last visit. |
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Term
| What must be kept on all pages of the records? |
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Definition
| Owner's name, address, phone number, Animal's name, species, age sex and breed. |
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Term
| Who owns medical records? |
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Definition
| The clinic, not the client. |
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Term
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Definition
| Must be backed up to an outside source every night. |
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Term
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Definition
All information is confidential.
Information may only be released with client consent.
Except: When involving a public health risk (ie rabies) |
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Term
| Info contained in medical records? |
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Definition
- Dates of custody for care.
- History including tpr
- Diagnosis
- Medication
- Vaccination Records
- Surgical Record
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Term
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Definition
Subjective: what the owner tells you
Must say per Ō or per C |
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Term
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Definition
Objective
The truth, what you observe
- Lab work
- x-rays
- ultrasounds
- P.E. and vitals
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Term
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Definition
Assessment
DVM's diagnosis
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Term
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Definition
Prognosis (plan)
What DVM will do to treat/ heal the animal.
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Term
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Definition
Contains info that is in the record but adds:
- Pre-op blood work
- Procedure
- DVM
- Anesthetist
- Pre-anes drugs
- Anesthesia start and stop time
- Endotracheal tube size
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Term
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Definition
- Euthanasia
- surguery
- necropsy
- treatment
- boarding
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