What is a Veterinary Medical Record?

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  • 00:01 Medical Records
  • 1:26 Requirements for…
  • 2:50 Copies of Medical Records
  • 4:17 Lesson Summary
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Lesson Transcript
Instructor: Artem Cheprasov

Artem has a doctor of veterinary medicine degree.

This lesson will go over what a medical record is, what it contains, and why it's important from a legal standpoint. We'll also look at tips on how to properly keep one.

Medical Records

What is a medical record? It's a confidential medical and legal document that contains a client's contact information and patient's medical and surgical history, among other things. These other things include the patient's name and signalment, a patient's species, breed and color, age (or date of birth), gender (that is to say, sex), and whether or not the patient has been spayed or neutered (their reproductive status), as well as services rendered and dates thereof, copies of rabies and health certificates, laboratory results, and progress information.

If a written medical record is kept, as opposed to a fully computerized one, every client will have one folder unique to them and each patient owned by that client will be separated by a tab within that folder.

Note how I said a medical record is a legal document in addition to a medical one. This is because it's uber-important in cases of some sort of legal dispute. A medical record can make or break a case, and its contents (or lack thereof) can seriously support or damage a veterinarian's case.

It's also a confidential document. That means no information that is part of a medical record shall be released to or discussed with any non-essential party without a client's written consent. We're going to discuss many important aspects related to this critical document in this lesson.

Key Points

Because a medical record is a legal document, all written information in the medical record must be made in permanent ink, in legible handwriting, and be dated and signed (or initialed, as the case may be). If a legal team cannot decipher what is written or suspects someone of erasing part of the medical record, that's very bad news.

Illegible records or records using uncommon or unheard of abbreviations could lead to the wrong medical treatment of a patient, the wrong understanding of their medical history, improper client education, or the loss of a legal dispute.

So, if you ever write anything down in a medical record, make sure to use very legible print, not cursive, and use a pen, not pencil. If you ever make a mistake writing something down, never use white-out and never scribble something out with a pen to the point of illegibility. Instead, if you make a mistake, cross out the word or number in question with one line, write the correct information, date the correction, and initial your name next to the correction.

Computerized medical records are becoming more common, and they allow for automatic time stamping of entered information, corrections, and initials.

Copies of Medical Records

Although medical records are the property of the veterinary hospital, clients can request a copy at any time for themselves or if they need one for a new veterinarian or a referral, which is when an attending veterinarian (the referring veterinarian) sends a client to a specialist for advanced diagnostic and treatment care. A client may be charged a fee for such a copy.

When copying a medical record for a referral, only copy the information that is pertinent to the case and send any digital information (like digital X-rays) via a CD or DVD, or an e-mail access link, as the case may be.

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