Veterinary Medical Records: Form & Function
Published on August 22, 2018 by A. Rothstein
Veterinary technicians will work with both paper and electronic formatted veterinary medical records. The primary function of veterinary medical records is to provide excellent care to animal patients and document diagnostic procedures, diagnoses, prognoses and treatment. Veterinary medical records also provide a basis for evaluating the medical information for business, legal and research purposes.
The information that is collected in the veterinary medical records includes the pet owner’s information, patient information, immediate history of the problem or issue, patient history, physical examination notes, diagnoses, prognoses, diagnostic results, therapeutic plans, cautionary notes and financial records.
There are also many different formats that veterinary medical records are organized for veterinarians and vet techs to access quickly and easily. The different formats include Source-Oriented Veterinary Medical Records (SOVMR), Problem-Oriented Veterinary Medical Records (POVMR), Medication Administration/Order Records (MAOR) and Subjective Objective Assessment and Planning (SOAP) notes.
Source-Oriented Veterinary Medical Records (SOVMR)
In this style of recording-keeping and recording, patient’s information is kept together by subject matter. This is the best way for a vet tech to access information in chronological order, where access to the most recent information is located last and oldest information first. Although this type of organization of veterinary medical records is easy to train new veterinary staff on, it may lack the necessary detail needed during litigation. SOVMR organization also may be difficult if the veterinary facility has different departments that record procedures, diagnosis and treatment all on the same set of veterinary medical records.
Problem-Oriented Veterinary Medical Records (POVMR)
This style of record-keeping and recording organizes the veterinary medical records by problem. Each problem is given a number and the number is used throughout the medical record. Notes are written in SOAP format within the POVMR organization style. Within the veterinary medical records, the veterinarian focuses on the cause of the illness and possible cure whereas the vet tech focuses on the patient’s psychological and physiologic reactions. The American Animal Hospital Association (AAHA) endorses this type of record organization because it fosters team-oriented medical care and encourages on-going assessment of the patient’s condition.
Medication Administration/Order Records (MAOR)
A form of ward treatment sheet to assure that the hospitalized patient is given the treatment, diagnostic tests, and diet as requested by the attending veterinarian. The MAOR is used to give veterinary teams a summary of the patient’s management during hospitalization. Medication, procedures and treatments are performed throughout the day, many times by multiple vet techs, allowing the veterinary team to keep track of patient care by using MAOR notes organization.
Subjective Objective Assessment and Planning (SOAP) Notes
Patient evaluation and assessment is documented in the progress notes of a veterinary medical record using the SOAP format. All non-measurable information is categorized as subjective information and measurable information is categorized as objective information. Assessment of the patient’s initial problem and the physical examination findings are subjective and observations by the vet tech are objective. Further, any lab reports or vitals are noted in the objective section of the veterinary medical records.
Completion of the assessment section of the SOAP notes requires analysis of the subjective and objective data. At this time, the vet tech will generate a list of patient evaluations that reflect the animal’s condition. The last portion of the SOAP notes involves planning. The vet tech will create a plan to intervene based on the evaluation list in the assessment section of the SOAP notes. The patient care is carried out based on the plan section to restore patient comfort and well-being. As the patient is re-evaluated the action plan may evolve based on new developments and changes in the patient’s status.
Confidentiality of Veterinary Medical Records
The American Veterinary Medical Foundation (AVMF) helps vet techs with the publication of state and local confidentiality statutory and regulatory provisions. Many states do not allow the release of records without the pet owner’s consent, by court order or subpoena to comply with state or federal law. This is important for vet techs to consider when they receive requests for patient’s veterinary medical records.
Interested in learning more about veterinary medical records? Ready to start working as a veterinary technician? With an associate degree in veterinary technology, you’ll gain the knowledge and skills you need to start an entry-level career as a veterinary technician. Broadview University has been part of the community for more than 40 years, so we’ve developed connections that can help move your career forward. After completing our accredited degree program, you’ll be eligible to sit for the Veterinary Technician National Exam (VTNE). Passing the VTNE allows you to become a Certified Veterinary Technician (CVT), a designation that will give you a competitive advantage when you enter the job market.
Contact us today to learn more about becoming a veterinary technician and working in veterinary technology.
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