Chapter 2 Medical Records

Question Answer
alphabetical filing system organization of medical records by patient or client identification number and color coding
assessment veterinary diagnosis of problem
cage card identification and location of patient while in the care of facility
client the owner of the animal
color code method used to file medical records for visual ease of use
confidentiality maintenance of privacy of medical information
consent form permission given by owner to treat animal
health certificate documentation that an animal is in good health and can be transported out of state or county
medical record written and recorded information on the care and treatment of the animal
neuter certificate documentation that animal has been spayed or castrated and is not longer able to reproduce
numerical filing system organization of medical records by client or patient last name
objective information measured facts, example vital signs
patient the animal being treated
plan treatments or procedures provided
progress notes documentation chronologically detailing the patients history, treatment, and outcomes
rabies certificate documentation the animal has received proper vaccination for rabies
SOAP subjective information, objective information, assessment, plan, one method used for documentation in the medical record
subjective information observations of the animal's appearance and behavior made by the vet staff
Veterinary Client patient relationship (VCPR) relationship established between patient, client, and veterinary staff based on trust, expertise, and duty to care for an animal

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