| Term | Definition |
|---|
| signalment | patient information including age(recorded as date of birth), sex(including spayed, neutered or intact),species,breed,and color/markings |
| chief complaint CC | the reason the client wants the animal to be seen by the veterinarian |
| history Hx | the information provided by the client or obtained from prior medical records. |
| subjective S | the subjective section contains opinions or impressions of the animal's condition based on actual observations or physical examination(not based on patient history) |
| objective O | the objective section contains facts and information that can be clearly demonstrated or quantified-things that can be seen,heard,felt,measured or counted |
| assessment A | an assessment is the veterinarian's interpretation of the history,subjective and objective observations in order to evaluate the problem. |
| plan P | what will be done for the patient.this is usually recorded as a list with check boxes to be marked when the tasks are completed |
| WNL | within normal limits |
| how long must medical records be retained by the hospital? | must be retained for a minimum of three years following the patient's last visit |
| describe the proper procedure for correcting an error you made in the medical record? | if you make a mistake,put a single line through the mistake,sign and date it,and complete the correct entry.add an explanatory note if the reason for the correction may be unclear. |
| POVMR | problem oriented veterinary medical record |
Combine with other sets
Share on Facebook
Share on MySpace