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VTA 140 - Medical records and Log Book Handouts Flashcards | StudBud
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VTA 140 - Medical records and Log Book Handouts
VTA 140 - Medical records and Log Book Handouts
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Questions
30
Answers
1
Concerning Livestock records, what is an Estrus expectancy chart used for?
To determine which bull should mate to a particular cow
To determine the date of each estrus
To determine the birth dates of each calf
To determine when calves should be weaned
2
The written process of evaluating and adjusting therapeutic treatment plans is called a:
Working problem list
Database
problem-oriented veterinary medical record
SOAP
3
Vomiting and depression following chemotherapy, patient deteriorating; choose where it belongs in progress notes.
Plan
Objective
Subjective
Assessment
4
The _____-oriented medical record promotes team-oriented medical care, rapid retrieval of info, and boosts communication
Problem
Patient
Source
Treatment
5
When doesn't a Veterinarian require permission by owner to release pet's information?
Reporting a contagious disease to the USDA
A legal search warrant or court request for patient records
Information requested by a collection agency
During a divorce settlement, where custody of animal determined
6
After records have been kept for a min. of four years, it is proper office procedure to mail the records to the client.
False
True
7
Clark County
does not
require pets to have a license.
False
True
8
Which of the following is
not
a primary purpose of a medical record?
Supports continiuty of patient care across shift changes.
Provides date to conduct retrospective studies.
Create diagnostic and treatment plan post exam & history.
Documents instructions given to the owner when the patient is discharged.
9
Which staff members are responsible for proper/accurate medical records?
Licensed Veterinary Technician
Doctor of Veterinary Medicine
Receptionists
Veterinary Assistants
10
T: 101.5°FP: 90 bpmR: 12 bpm
Subjective
Plan
Assessment
Objective
11
Bright, Alert, Barking; choose where it belongs in progress notes.
Assessment
Subjective
Plan
Objective
12
Abdominal ultrasound to be performed this afternoon; choose where it belongs in progress notes
Assessment
Plan
Objective
Subjective
13
The "S" in SOAP stands for:
Standard
Surgery
Subjective
Signalment
14
Although impractical, it is required that food animal DVM maintain individual medical records for each animal in a herds
False
True
15
Nevada law requires all hospitals to have consent forms for euthanasia, hospitalization, anesthesia, surgery, & Tx.
True
False
16
What is legally required to be included in a medical record?
Medication/ Treatment
Surgical Record
Diagnosis / Prognosis
Vaccine History
Owner and client information
History, TPR, & Weight
17
Entries in a medical record should be written in:
Any color as long as information is recorded
Red Ink
Blue Ink
Black ink
18
Slight bleeding at surgical site 24 hours after onychectomy; choose where it belongs in progress notes.
Assessment
Objective
Subjective
Plan
19
For which of the following procedures is it critical that the owner completes and signs an informed consent form?
Radiographs
Euthanasia
Ear Flush
All of the above
20
Which part(s) of the SOAP might a veterinary assistant complete?
Assessment
Both Red & Blue
Subjective
Objective
21
In Nevada, you must get a Health Certificate when crossing your pet between state lines.
True
False
22
A Health Certificate, by law, must include an examination by a licensed DVM how many days prior to travel?
3 days
30 days
10 days
1 day (24 hours)
23
Negligence" is best defined as:
Departure from the standard of practice of veterinary medicine
A deviation from the standard of care
Failure to comply with a client's request
Lack of knowledge or skill in a professional obligation
24
How should errors be documented in medical records?
Use erasable ink so errors can completely erase
Draw a line through the mistake and initial next to it
Use white out to cover the error, and then initial and date
Write the correct information in the margin, then initial and date it
25
The client is the legal owner of their pet's medical records.
True
False
26
Remove urinary catheter and culture it. Monitor and record volume of urine produced over next 24 hours. (progress notes)
Subjective
Plan
Objective
Assessment
27
Medical records are considered legal docs that insurance companies may require to assess whether a claim is to be paid.
True
False
28
Medical records that have limited space typically use the ________-oriented patient record format.
Source
Treatment
Problem
Patient
29
Radiographs are the legal property of:
The veterinary practice where they are taken
the owner of the pet
the radiograph company who supplies the machine and the film
The State boards of Veterinary Medical Examiners
30
In the problem-oriented vet. medical record, the database consists of the signalment, PE, diagnostic tests, and_______.
Logs
Primary complaint
Working list problems
History
