Veterinary Medical Records

• Medical records support patient care by:
  • Identifying the owner and patient.
• Supporting logical assessments and plans.
• Ensuring continuity of care.
• Facilitating communication between the owner and medical team.
• Secondary purposes of medical records include:
  • Serving as legal documents.
  • Addressing errors.
  • Tracking business transactions.
  • Usefulness for case studies and population retrospective studies.

Types of Medical Records

• Paper patient records, letter-sized and held in folders.
• Paper patient records are held together with fixed clips or loose pages with page numbers and names on each sheet.
• Paper patient records include all other paperwork and are organized in reverse chronological order.
• Paper card files utilize pouches for multiple animals, with one patient card per pouch and lab results folded inside.
• Paper card files are considered too small for thorough medical records.

Computerized Files

• Computerized files cannot be altered to serve as legal documents.
• They allow multiple staff to access information simultaneously.
• Computerized files eliminate the need to "walk" paper medical records and can utilize voice recognition technology.
• Logs serve as a record of daily activity.
• Logs provide additional documentation for legal support.
• Logs supply data for analysis and retrospective studies and are required for AAHA accreditation.

Format of Medical Records

• Source-Oriented Medical Record (SOMR) organizes information based on the point of origin.
• SOMR includes DVM's notes, nursing records, medications, and lab results.
• SOMR presents challenges in tracking specific problems due to varied locations of information.
• Problem-Oriented Medical Record (POMR) provides a structured and logical framework.
  • POMR includes a defined database, master problem list, plan, and progress notes.
  • POMR is required for AAHA accreditation
• POMR provides a structured approach for navigating complicated cases and uses SOAP or HEAP systems.
• POMR Components include Master Problem List containing major medical disorders experienced over the patient's lifetime, in chronological order with date and resolution status for an overview of the patient's medical history.
• Working Problem List is a dynamic and regularly updated list of patient medical conditions and are tools for DVMs/RVTs to prioritize and manage patient care.
• Example entries for the working problem list include:
  • Renal disease (diagnosis)
  • Diarrhea (clinical sign)
  • Dehydration (clinical sign)
  • Skin issue (?)

SOAP/HEAP Format

• Subjective information is obtained from the client and includes:
  • The reason for the visit.
  • Patient's history.
  • Observations made by the client.
• Objective/Exam information is gathered from the patient and includes:
  • Physiological data.
  • Physical exam (PE).
  • Diagnostic workup (lab results, radiographs, EKG).
• Assessment is a diagnosis based on subjective and objective information and includes:
  • A problem list
  • Differential and tentative diagnosis
  • Reasons for inclusion and exclusion
• Plan is developed by the veterinarian based on the assessment and may include:
  • Treatment/diagnostic tests.
  • Surgery.
  • Medications.
  • Communications.
• Progress notes are the main body of the medical record.
• Progress notes contain:
  • Notes from each recheck and during hospitalization
  • Results of physical exams
  • Medications administered
  • Patient's urine, bowel movements, vomiting
• Progress notes follow SOAP or HEAP format.
• Pertinent forms include:
  • Anesthetic record.
  • Diagnostic procedures.
  • Dental record.
  • Consent forms.
  • Additional relevant forms.
• Consent/authorization forms outline specific conditions and risks of procedures, serving as legal evidence, useful in challenging client interactions, and provide backup documentation.

Urogenital System

• Evaluated during abdominal palpation.
• Assess a Urinary Bladder; fluctuant/soft is good!
• Vulva/Prepuce: Check for discharge and swelling
• Testicles: Assess size, look for masses, pain, firmness
• Check for Cryptorchidism: inguinal/abdominal

Musculoskeletal System

• Assessment Methods include:

  • Gait assessment
  • Palpation of head & limbs
  • Look for asymmetry
  • Check for atrophy/degeneration
  • Evaluate swelling
  • Check Range of Motion (ROM)

• Palpation & Visual Exam for Ears:

  • Inspect pinnae and external ear canal
  • Look for hematomas, dermatitis, tumors, exudates, etc. Otoscopic Exam

• Tympanic Membrane:

  • White translucent = normal
  • Red, ruptured = problem

• Eyes Assessment Areas:

  • Position and discharge of eyes
  • Eyelids: check for entropion vs ectropion (usually lower eyelid)
  • Sclera: assess color
  • Cornea: check for ulcer and opacities

Lymph Nodes

• Palpation Techniques:
  • Palpate bilaterally
  • Compare size & shape
• Normal Findings:
  • Round to oval
  • Slightly moveable
  • Firm, slightly compressible
• Enlargement:
  • Focal or generalized
  • Slight enlargement in young (under 6 months) is normal
• Locate:
  • Submandibular: Ventral aspect of neck near angle of jaw
  • Axillary & Inguinal: Palpable when enlarged
  • Prescapular: Cranial to shoulder joint
  • Popliteal: In fat pad, caudal to stifle joint
• Potential Differentials Based on Findings for Single Enlargements includes:
  • Lipoma
  • Reactive lymph node
  • Abscess
  • Metastatic neoplasia
• Regional Enlargement:
  • Reactive lymph nodes
  • Lymphosarcoma
  • Metastatic neoplasia
• Generalized Enlargement:
  • Lymphosarcoma
  • Sepsis
  • Leukemia

Nervous System

• Assessment Components:
  • Mentation (mental activity/state of mind)
  • Cranial Nerves
  • Gait assessment/posture
  • Postural reactions
  • Spinal nerve reflexes
• Mental Status:
  • Alert & responsive
  • Dull: decreased responsiveness
  • Obtund: semi-responsive, arousable
  • Stupor: non-responsive except to noxious stimulus
  • Coma: non-responsive even to noxious stimulus
  • Disoriented: confused, loss of bearings
  • Demented: inappropriate response to environment/stimuli
• Cranial Nerves:
  • 12 pairs of sensory/motor or both!
• Observations:
  • Facial symmetry
  • Muscle tone
  • Eye movements
• Tests:
  • Menace response
  • Pupillary light reflex
  • Palpebral reflex
  • Hand clap response
  • Gag reflex
• Gait & Posture Assessment:
  • Incoordination (ataxia)?
  • Muscle weakness (paresis)?
  • Circling (large vs small; direction)?
  • Lameness?
  • Abnormal body posture (leaning, arched back, head tilt)?
  • Head pressing?
  • Recumbent appearance?
• Postural Reactions evaluates both proprioceptive & motor systems.
  • Proprioception: ability to sense body position/movement
• Spinal Nerves Reflex Tests:
  • Withdrawal reflex
  • Patellar reflex