medical records 2
TRANSCRIPT
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
Paper/paperless/paper lightPaper/paperless/paper light
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
Paper/paperless/paper lightPaper/paperless/paper light
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
Paper/paperless/paper lightPaper/paperless/paper light
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
Paper/paperless/paper lightPaper/paperless/paper light
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
Paper/paperless/paper lightPaper/paperless/paper light
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.
Paper/paperless/paper lightPaper/paperless/paper light
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