Chapter 2: Medical Records
TRUE/FALSE
1. Never write in pencil when recording in a veterinary medical record.
2. The veterinary-client-patient relationship or VCPR must be maintained legally within 2 years.
3. The health certificate must include vaccine dates of an animal.
4. The veterinary assistant must record an animal’s history, but it is not necessary to note any
communications with the client by phone or verbally within the medical record.
MULTIPLE CHOICE
1. Which of the following vaccines is legally required to be given to some animal species?
a.
distemper vaccine
c.
lyme vaccine
b.
feline leukemia vaccine
d.
rabies vaccine
2. How many years are many states required to keep medical records?
a.
10 years
c.
5 years
b.
7 years
d.
3 years
3. Which of the following filing methods is most commonly used in a veterinary facility?
a.
numerical filing
c.
color coding
b.
alphabetical filing
d.
free filing
4. Where is the SOAP recording method commonly used?
a.
vaccine records
c.
master problem list
b.
consent form
d.
progress notes
5. The temperature and heart rate of an animal is an example of __________ information.
a.
subjective
c.
assessment
b.
objective
d.
plan
6. Which of the following is a DO when recording in a medical record?
a.
erase all errors
c.
place a single line through errors
b.
write illegibly
d.
use common language
7. Which of the following statements is TRUE about the confidentiality of medical records?
a.
The only time information can be shared is for the purpose of patient care.
b.
It is okay for the information to be shared with anyone associated with the hospital.
c.
It is okay to share information with your family members.
d.
Veterinary medical records are not confidential, only human medical records are
confidential.
8. In the SOAP format for progress notes, in which category would the chief complaint be written?
a.
subjective information
c.
assessment
b.
objective information
d.
plan or procedure
9. Which of the following statements about filing medical records is NOT true?
a.
A color that is our of order is easier to identify than either numbers or letters that are out of
order
b.
Because no one is perfect, owners are sympathetic when thier records have been misfiled
c.
Numeric filing requires a way to cross-reference the client’s name with the client’s file
number
d.
More misfilies occur with alphabetical filing
10. Who owns the physical medical record?
a.
the client
c.
the state
b.
the patient
d.
the veterinary practice
11. Which statement about recording information on the medical record is NOT true?
a.
Medical records are legal documents
b.
Do not try to erase or obliterate an error entry
c.
Stamps and stickers should not be used on medical records because they ae legal
documents
d.
All entries are written in dark ink, either blue or black
12. When discharging a client and patient, which is NOT necessary for the veterinary assistant to check?
a.
that discharge instructions are clear
b.
that client has all of the prescribed medications
c.
that the client has made a follow up appointment, if necessary
d.
the veterinary assistant should check all of the above
COMPLETION
1. Place one single line through any error made in the medical record and then correct and _________ the
mistakes.
2. Each letter of the alphabet label is assigned an individual __________.
3. Progress notes are recorded in __________ order in the medical record.
4. The ________ details a patient’s past surgeries, medical conditions, and vaccines.
5. The __________ is the reason the veterinarian is seeing the patient during an appointment.
MATCHING
Match the following terms with the correct definition.
a.
the animal seen by the facility
b.
relationship between vet and animal owner
c.
opinion of animal’s appearance and attitude
d.
log entries made of each treatment
e.
proof of a spay or castration surgery
f.
form to allow an animal to travel
g.
vet’s diagnosis of an animal’s problem
h.
the owner of an animal
i.
identifies procedures to the owner and allows the owner to authorize them
j.
detailed information written about each animal
k.
treatment or procedure given to an animal
l.
measured facts based on an animal
m.
method of filing medical records
1. objective information
2. patient
3. medical record
4. consent form
5. assessment
6. neuter certificate
7. plan
8. progress notes
9. subjective information
10. health certificate