Medical Record
In 1968 Lawrence Weed published on the use of the problem- oriented medical record. This system of record keeping emphasizes the justifications for daily decision making during hospitalization.
Problems are defined by the history, physical examination, and laboratory findings. Daily (or more frequently for intensive care unit patients) subjective findings (e.g., appetite, attitude) are documented, and objective data (e.g., heart rate, temperature) are recorded. This information (e.g., patient is febrile) is then assessed by the clinician, and a plan (e.g., resubmit laboratory tests, change antibiotic medications) is derived based on the assessment. The abbreviated form of this type of medical record is SOAP, and this method is applied to each problem identified. Although the system encourages medical judgment and accountability, it more directly serves as a teaching tool within institutions by which the student's clinical thinking can be evaluated by the in-charge clinician. In private practices the method of record keeping is more flexible and tends to document vital information that primarily serves as an accounting of services and provides a medicolegal record. Unfortunately, many medical records function only as invoices and do not record medical information regarding the patient. This is more often true of ambulatory records but can be found in certain hospital practices. State veterinary regulatory bodies have strict requirements regarding the patient medical record, with particular regard to the administration and crossdocumentation of controlled substances (e.g., ketamine, butorphanol) and euthanasia solutions. Whichever system is used, the responsibly prepared medical record should provide medical information, justification for charges, a protection from liability, and adherence to state and federal regulations. A thorough medical record further allows for the retrieval of retrospective information. The accumulation of data is beneficial to the communication of clinical caseload experiences to other clinicians for the benefit of their patients.Medical Record Filing
Two major systems of medical record filing exist: numeric and name filing. Numeric systems offer consistency of the record and avoid the confusion of patients with similar names. The problem of name similarity is primarily confined to the nonregistered breeds of horses. Breed registration requires name approval to avoid duplication, among other undesirable designations. Again, for record-keeping purposes, clinic or ambulatory records for unnamed young horses are best designated by the dam's name and the foal's year of birth (e.g., Curious '06) and filed by month and year of examination. A “master” admission log should be maintained for record retrieval purposes, especially when a patient has been seen on multiple occasions. Color coding, along with numbering of the file folders, may be helpful in record retrieval. Computers offer the advantage that records can be retrieved through any one of several recall parameters (e.g., problem, client).
Computer-Generated Medical Records
Traditionally, patient medical records (PMRs) are maintained via a manual, paper-based, on-site system of data storage and retrieval as described previously. Before computerization and its acceptance by the medical community, all information regarding patient history, diagnostic testing, and treatment notes was handwritten and filed. Unfortunately, a number of problems coexist with a paper-based system, including illegible handwriting by practitioners or staff, poor integration of patient information (e.g., diagnostic test results and imaging studies filed separately from the PMR), and loss of or damage to files.14 In addition, state veterinary boards require that all patient records and imaging studies be retained by a practice for a minimum period of time before they can legally be disposed of. Storage issues can be a problem for equine practices that do many prepurchase examinations, in which radiographs may be retained for 10 to 20 years.
Although many veterinary facilities currently use computers for various tasks such as accounting and inventory, few have eliminated the paper-based PMR completely.Computers offer the advantages of legibility, quick data retrieval, and immense archiving capacity. The need for rapid transfer of medical information from doctor to doctor or from doctor to referral facility is being met by advances in computer software and Internet access. Thus the current trend in human and veterinary medicine is the development and implementation of an electronic medical record (EMR) that is entirely computer generated. An EMR permits one or more individuals, simultaneously, to access laboratory results, imaging studies, and other pertinent patient information.15 For the equine practitioner, the availability of real-time ultrasound imaging and digital radiography has revolutionized the production and transmission of high-quality diagnostic images, via computer, within moments after they have been taken. This has greatly increased the quality of medicine and efficiency of patient care, allowing general practitioners rapid access to the opinions of specialists at sites distant from the patient. Over time, acceptance of the EMR may result in the complete dissolution of the paper-based medical record.
Several software systems have been designed specifically for equine hospitals and include adaptations for ambulatory “off-site” data entry and retrieval (Henry Schein Veterinary Solutions, Piedmont, Mo.; Business Infusions, Calgary, Canada).
In addition to patient information, other applications such as client invoicing, inventory management, and payroll are included in certain software packages. Recently, voice recognition software has been adapted for use by veterinarians (Dragon Veterinary, Antigonish, Canada) and can be added to most software packages and implemented by using either a specialized microphone plugged into an in-house computer or a “cloud”- based mobile phone application.
This system promises to improve efficiency and accuracy and save time by allowing ambulatory practitioners to enter data directly into the EMR through the app on their mobile phone at any time, either during the examination or while traveling between client locations.Three basic types of systems are currently available to the equine practitioner: standalone and multiuser on-site systems; on-site systems with external synchronization; and Internet-based multiuser systems. The first and second types of systems are similar, but with the addition of external synchronization, patient information can be collected on handheld devices or laptop computers away from the main hospital (e.g., by ambulatory staff) and downloaded directly to an in-house computer. The third system is the most technologically advanced and offers not only greater efficiency but also the ability to continuously upgrade software. This system offers access to the Internet through either a hospital web page or a client Internet server and allows practitioners in the field the ability to transmit information such as digital radiographs immediately to other doctors, referral hospitals, or specialists throughout the world. These connections can be made via wireless (e.g., mobile phone) or direct Internet access (e.g., phone line, cable). Currently, IDEXX Laboratories in Westbrook, Maine, and VCA Antech, Inc. in Los Angeles can send test results directly to the PMR as soon as they are available. Another advantage of this system is that all information contained in the EMR can be stored on an off-site server and downloaded to the hard drives of in-house computers.
This technology can be a cost-effective, important tool in modern practice management that increases efficiency and quality of patient care and dramatically reduces storage requirements.
Record Keeping for Special Purposes
The U.S. Drug Enforcement Administration (DEA) requires veterinary practices to maintain detailed inventory records for scheduled drugs.
Drug inventory and use must be recorded in a readily retrievable medical record. Requirements may vary by state, so consultation with state regulatory agencies is prudent. Use should identify the patient, volume used/wasted, date, and authorized person who obtained the drug. The drug use should be further documented in the PMR to account for the volume having been depleted from the inventory. For scheduled drugs, states may vary as to the required timing and frequency of inventory accounting and/or inspection for veterinary practices, including ambulatory vehicles.Occupational Safety and Health Administration (OSHA) records are comparable to the DEA ongoing inventory and use records and are stringent in terms of compliance with OSHA regulations.16 Documentation regarding safety procedures (e.g., fire safety inspections) is required after an initial inspection for labeling and safety protocol. Upgrading of Material Safety Data Sheets (MSDSs) is a further requirement and should comply with current standards.
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