MEDICAL RECORDS: THE ROAD MAP TO QUALITY CARE
Excellent veterinary medical record keeping protocols are core to the ability to deliver quality care to patients. It is not possible to overstate the value of accurate, clear, and complete medical records. Unfortunately, medical records are often delegated to the "I will do them when I get a chance" pile and important information is either forgotten or misremembered. Also, even when handled promptly, poor record keeping protocols result in incomplete records that are often hard to read and confusing.
Take an honest appraisal of the record keeping requirements at your practice. What if a number of months after seeing a patient the animal's owner decided to take the practice to court in an attempt to prove malpractice? Would the patient's medical record serve as non-verbal proof of quality care or would it reflect poorly on the practice? Would the medical record help or hinder the practice's defense? Most veterinary professionals have heard that if it is not in the medical record "then it didn't happen." Often it is the gaps in the medical record that speak the loudest.
Medical records provide a road map, from start to finish. Is the path clear, with each step along the way documented and the plan for the next step clearly laid out? Or is it a confusing jumble of halting steps without clarity and focus? Could another professional, totally unfamiliar with the patient, pick up the medical record and immediately understand prior history, testing, differentials, treatments and patient response? Is client consent and client refusal for recommendations legally documented? Does the practice's medical records aid in increasing patient follow-up and client compliance?
Medical Records: The Roadmap to Quality Care is a 3-week course that provides the foundational knowledge needed to develop sound practice protocols for all members of the veterinary practice team.
The audit section of this course requires access to about 10 random patient charts. Submission of the actual records or submitting private information is in no way required. Instead an audit form is used to submit findings.
|Continuing Education Credits
Course meets the requirements for 10 RACE hours of continuing education credit for veterinary technicians and veterinarians in jurisdictions which recognize AAVSB's RACE approval. However, participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery.
This course is applicable for 10 CE credits toward the continuing education requirement for the Certified Veterinary Practice Manager program offered by the Veterinary Hospital Managers Association (VHMA).
This course is an interactive online course that meets RACE requirements; program number 57-11268.
For participants who need pre-authorzation from a state board or other group, please use this document, Medical Records Information. It may be downloaded and then printed or attached to an email.
Medical Records: The Road Map to Quality Care is a 3-week course that discusses recordkeeping topics including standard abbreviations, typical medical record formats, keeping accurate medical records to ensure decreased violation risks, and the benefits of medical record audits to increase compliance. In addition, logistical topics such as paper vs. paperless medical records and electronic medical record software are discussed.
A large component of the course is devoted to decreasing medical record violations, defining appropriate owner consent and ownership/retention of medical records.
|Course Focus and Learning Objectives
Medical Records: The Roadmap to Quality Care is designed for any practice, veterinarian or team member that is interested in understanding and improving medical record management. This course is broken down into easy to understand sections that any team member can understand regardless of their position within the practice.
Upon completion of the course, the student will be able to:
- Recognize basic elements of complete medical records
- Describe why proper recordkeeping is important for a veterinary practice
- List commonly used medical record abbreviations
- Explain the function and benefit of a SOAP format
- Recognize compliance issues, and the role of the medical record in improving it
- Design and implement a medical records audit system
- List the advantages of electronic medical records
- Design and implement a successful program to purge and dispose of medical records
- Identify common medical record violations that occur in veterinary practices
- Perform correct and appropriate medical record entries
- Develop appropriate owner consent forms that are tailored to individual cases
|Participation Access Parameters
The design of this course allows participants to enroll at any time. After enrolling, please allow up to 48 hours for course activation.
Each participant will have a personal start and end date that begins upon activation.
...Stressing how important record keeping is was a great motivation for proper record keeping as it is easy to take short cuts sometimes - which may not always be worth it.
...I cannot say one thing was the most beneficial to me. The course was beneficial overall from the educative material to the examines. I did strongly appreciate the course study assignments because it give a study key to compare them to.
...Reminded me of the SOAP procedure in more detail, provided me with a method of auditing myself and my clinic, very interesting and of great clinical and practical use, easy to take the information and apply it right away
...The information was well organized, written and easy to understand. I thought the assignments were well thought out and very instructional.
...I found the Record audit system and the Abbreviations sections helpful
...The straight forward information let me see what I was not putting in the records and it was easily corrected
...The case workups were somewhat beneficial. I was able to alter some of my methodology from this. Understand some aspects of SOAP I did not understand.
...I thought this was a great course! You really had to interact and put some thought in to it. I feel that I typically have good medical records but this has given me the structure to move to the next step with them to ensure everything is included. I also am excited to implement an audit system to help hold everyone accountable for their actions or lack of actions.
|Course Completion Requirements
Completed students are awarded a certificate of completion. Completion requirements include:
- Instructor Graded Interactive Module Assignments: Designed to help the participant reinforce newly learned material
- Instructor Graded Interactive Case Study Assignments: Designed to help the participant apply the newly learned skills and knowledge though patient and practice based scenarios
- Examinations: All examinations must be submitted with a score of 80% or better
- Course survey
Leslie Lynette, RVT, CVPM
Veterinary medicine is the career path that Leslie chose at a very young age. As a five-year-old child, she rescued baby rabbits from the family dog after it disrupted their nest. Leslie cared for the survivors and sent them on their way when they became stronger. This was the point at which Leslie knew what she wanted to do in life. After eighteen years of clinical experience in managing veterinary patient care as a Registered Veterinary Technician and Certified Veterinary Practice Manager, Leslie feels honored to be able to give back to the profession and to contribute to the development of colleagues in this field.
Leslie has had the opportunity to experience all areas of the veterinary practice. In 1995, Leslie completed an Associate in Applied Science in Veterinary Medical Technology and upon passing the NVTE became a Registered Veterinary Technician. After several years working in practice and a multitude of continuing education, hard work and training, she was given the designation as Practice Manager. In 2001, Leslie began working as the Hospital Administrator for a group of veterinarians that owned several practices, one of which being a 24 hour emergency care center. In 2008, Leslie earned the designation of Certified Veterinary Practice Manager. Leslie has a genuine passion for the advancement of training and education for managers, technicians, assistants and client support staff.
Leslie is married to her high school sweetheart and together they have one vivacious young daughter that keeps them on their toes. Leslie and her family recently lost their beloved dog Chloe after 15 years and now share their home with a curmudgeon old kitty named “Mr. Willis”. When not writing courses for VetMedTeam, Leslie enjoys boating on the lake, photography, stained glass design and spending time with her family.
Favorite Quote: “The definition of insanity is doing the same thing over and over again and expecting different results.” Albert Einstein