Purpose of taking History?
to obtain from client all information pertinent to animals health.
Which patients must be seen inmediately ?
a)Respiratory problems b)Severe injuries,including hemorrhage c) Bloating (GRV) d) Convulsions lasting longer than 5 minutes
Patients to be seen same day?
a) Eye Problems b) Vomiting, Depression c) Coughing d) Difficulty Giving Birth e) severe vomiting/diarrhea have owner bring stool sample
What is SOAP ?
SOAP is written as part as the patients record for each problem presented .
a)Subjective information: species,age,breed,sex,color, markings,name,habits environment, surgeries.
b) Objective info: findings related to the problem, physycal exams findings like xrays, lab treports, diagnosis, treatment, progress notes.
c) Assesment: evaluation of patients status
d) Plan: course of treatment for patient.
Medical Records standards
a)Medical records should always be written in black ink only.appointments is only can be written with pencil.
b)following should be done only if an error:
-Draw a single line through error
-Write the correct word or phrase above.
-Write the word correction or corr in the margin the initials of person making the correction and date .
AAHA American Animal Hospital Association mandatory requirements :
a) legible individual record containing separate list of patients problems mantained on every patient administered to or by the hospital. problems under medical or surgical management must be identified
b) records must be documented accuretely and in manner where time and date are recorded , records must be accesible at any time so retrieval can be inmediate.