stud
bud
Sign up
Log in
Home
Library
Explore
SAT
More
VS104 Medical Records Flashcards | StudBud
Explore
/
VS104 Medical Records
VS104 Medical Records
35 terms
·
StudBud Administration
·
59 plays
Imported from external platform
Flashcards
35 cards
F
Practice quiz
P
Host live
L
Questions
35
Answers
1
What are discharge guidelines?
When patient goes home, why, and who will take them home
What the owner has to follow when taking the patient home
Who is in charge of the patient outside of the hospital
2
Do you document the time of discharge and who picked up the patient?
False
True
3
Evaluations that are an assessment of progress
Subjective data
Plan
Objective data
Assessment
4
Diagnostic test results
Database
Vaccination sheets
Flowsheets
Lab results
5
____ of care for an animal; original or revised plan
Objective data
Assessment
Plan
Subjective data
6
What are flowsheets?
Anesthesia sheet and medical treatment records
Diagnostic test result sheets
Medical treatment records
Daily hospital notes on the patient
7
If you make a mistake on a medical record document you should...
Leave it and start a brand new sheet
Make a single line through the word, write error and initial it
Erase it and start again
Write a line through it and continue writing
8
All handwritten entries should be made in black ink
False
True
9
PVMR stands for...
Problem Oriented Veterinary Medical Records
Post Operative Veterinary Medical Records
Pre Operative Veterinary Medical Records
Practice Organized Veterinary Medical Records
10
Documentation can be the same as what is on the database or flow sheet?
False
True
11
Is an index to the patients medical history
Master problem list
Database
Intake information
Working problem list
12
SOVMR stands for...
Stop Overusing Veterinary Medical Records
Source Oriented Veterinary Medical Records
Source Organized Veterinary Medical Record
Shut Out Veterinary Medical Records
13
Data is collected through physical exams or review of lab results
Assessment
Subjective only
Objective only
Subjective & objective
14
The focus of SOAP notes is on the specific problem or problems the animal is being treated for
False
True
15
A SOAP note is written when the animal is first seen and then _______ after that
At least daily
Twice a day
Dependent on the condition of the animal
Only once
16
Physical exam forms and other test results make up the diagnostic _____ for the patient
Pre surgery report on the patient
Flow sheet
Diagnostic sheet
Medical discharge sheet
17
Why is SOAPing important for each patient?
Reports on how the animal is doing day to day
Important information that is included in the patients history file
Primary means of communication about the patient to other vet clinic staff
Each animal needs an assessment when they stay in the clinic
18
Based on identified evaluations, list appropriate interventions for each evaluation
Plan
Objective data
Subjective data
Tech assessment
19
Contains only data that has become available since the last data was recorded
SOAP note
Notation
Flow sheet
Database
20
What does SOAP stand for?
Subjective, objective, assessment, plan
Subjective,objective, assessment, prevent
Source, objective, assessment, plan
Subjective, objective, arousal, plan
21
Who do you review potential complications with at discharge?
The owner
The patient's "dad"
The person who came to pick up the patient, owner or not
The patient's "mom"
22
Provides documentation of every medication and IV fluid, treatments, tests and diets given to an animal during its stay
Medical Administration/Order Record
Working Problem List
Master Problem List
Vaccination sheet
23
Based on collected data, rank and identify appropriate technician evaluations
Plan
Subjective data
SOAP
Assessment
24
POVMR goes through..
Each patient individually
Each date and time the patient came into the clinic
Complicated medical cases one problem at a time
Combines all the patients medical history randomly
25
What is a veterinary medical record?
A document only filled out before a surgery procedure
A report that goes home with the owner after their animals appointment
A list of everything an animal has received upon a vet visit
Written info, reports and communication on an animals veterinary visits
26
Information is entered from various sources by chronological order
POVMR
AbVMA
MPL
SOVMR
27
An MAOR provides______ only for hospitalized animals
Vaccination protocol and treatment protocol
What surgery was performed and why
SOAP notes
What medications were given, when treatment is next, what test results were
28
Pertinent signs/symptoms that are observable but not really measurable
Master problem list
Subjective data
Assessment
Objective data
29
Why might a demonstration of technique be done at discharge of the patient?
To show the owner the proper technique to administer treatment
To show the owner the technique of taking out stitches
To show the owner specifically how to give an injection
To show the owner how to feed their animal properly
30
Can physical exam findings be considered subjective?
False
True
31
The owners name, address and billing information
Progress report
Database
Vaccination sheet
Intake information
32
Pertinent signs or symptoms that are measurable or quantifiable
Plan
Objective data
Subjective data
Assessment
33
A veterinarian will create a plan that will include diagnostics and treaments
False
True
34
A veterinary medical report is not a legal document
True
False
35
Communications about the animals response to treatment
Referrals
Progress report
Flowsheets
Discharge summary
