MEDICAL RECORDS: THE ROAD MAP TO QUALITY CARE

Course Overview
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 remembered incorrectly. 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. The audit section of this course requires access to about 10 random patient charts. Submission of the actual records or submitting private information is not required. Instead an audit form is used to submit findings.

Course Overview

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 remembered incorrectly. 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.

The audit section of this course requires access to about 10 random patient charts. Submission of the actual records or submitting private information is not 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, printed, or attached to an email.

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, printed, or attached to an email.

Course Content
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 Content

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 to help veterinarians and technicians improve their medical record keeping skills. The audit section of this course requires access to about 10 random patient charts. Submission of the actual records or submitting private information is not required. Instead an audit form is used to submit findings. Upon completion of the course, the student will be able to: Recognize basic elements of complete medical records Describe why proper record keeping 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

Course Focus and Learning Objectives

Medical Records: The Roadmap to Quality Care is designed to help veterinarians and technicians improve their medical record keeping skills.

The audit section of this course requires access to about 10 random patient charts. Submission of the actual records or submitting private information is not required. Instead an audit form is used to submit findings.

Upon completion of the course, the student will be able to:

Recognize basic elements of complete medical records
Describe why proper record keeping 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.

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

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

Participant Feedback
...critical thinking exercise really revealed how poor the medical records have been historically for this practice ...The info was thorough and useful for learning better techniques for keeping medical records. The case studies were interesting although quite difficult for someone who has absolutely zero experience with dogs. ...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 What a DIFFERENCE it has made in our practice in a very short time. I will tell you that I came to this course with a chip on my shoulder and am so PLEASED that I took this course. I believe that we as a practice will see invaluable positive results because of this information. The course was designed very well and made me THINK instead of just kicking back correct information to a question. And then when I looked at our current sample of records and evaluated them for the first time, I was aghast. These notes will be referred to again and again. Thank you VERY MUCH TO THE ENTIRE TEAM for this course! It was so worth the money and I would recommend that anyone who handles patient records take this course for themselves.br /> 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. Emphasis on completeness of records and need to document everything was good for me. As a solo practicioner in a busy practice I tended to write down just enough for me to know what was going on, that would leave me vulnerable to complaints. ...Well organized and clear. Assignments were appropriate and relevant... I feel that overall this class has helped me to review what a complete medical record consists of and how to better implement an audit system in clinic so that we can improve our overall record keeping. The different types of medical record organization methods were most beneficial to me. The mixture of course assignments and quizzes were helpful in reinforcing the information. I will use the medical record audit to benefit my team. The instructor was available by email for issues navigating course. Leslie Lynette is an asset. Without her help, submission of assignments probably not accomplished. She appears very knowledgeable, practical and amicable. Content good. 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. I felt the "Roadmaps To Quality Care" printout was extremely helpful and will serve as a good reference guide. The learning exercises were good to realize how sloppy my format has become in my medical records. I enjoyed the ideas and insights to implement in my clinic. The resources to use are very helpful.. Concise and easy to read course materials, direct and to the point. Learning about the audit process was helpful, and it's something that I can take back to my team. It was very beneficial to pull actual records from my practice and perform an internal audit. It became very clear what areas of our medical record keeping need attention.

Participant Feedback

...critical thinking exercise really revealed how poor the medical records have been historically for this practice

...The info was thorough and useful for learning better techniques for keeping medical records. The case studies were interesting although quite difficult for someone who has absolutely zero experience with dogs.

...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

What a DIFFERENCE it has made in our practice in a very short time. I will tell you that I came to this course with a chip on my shoulder and am so PLEASED that I took this course. I believe that we as a practice will see invaluable positive results because of this information. The course was designed very well and made me THINK instead of just kicking back correct information to a question. And then when I looked at our current sample of records and evaluated them for the first time, I was aghast. These notes will be referred to again and again. Thank you VERY MUCH TO THE ENTIRE TEAM for this course! It was so worth the money and I would recommend that anyone who handles patient records take this course for themselves.br />
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.

Emphasis on completeness of records and need to document everything was good for me. As a solo practicioner in a busy practice I tended to write down just enough for me to know what was going on, that would leave me vulnerable to complaints.

...Well organized and clear. Assignments were appropriate and relevant...

I feel that overall this class has helped me to review what a complete medical record consists of and how to better implement an audit system in clinic so that we can improve our overall record keeping.

The different types of medical record organization methods were most beneficial to me.

The mixture of course assignments and quizzes were helpful in reinforcing the information. I will use the medical record audit to benefit my team.

The instructor was available by email for issues navigating course. Leslie Lynette is an asset. Without her help, submission of assignments probably not accomplished. She appears very knowledgeable, practical and amicable. Content good.

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.

I felt the "Roadmaps To Quality Care" printout was extremely helpful and will serve as a good reference guide. The learning exercises were good to realize how sloppy my format has become in my medical records.

I enjoyed the ideas and insights to implement in my clinic. The resources to use are very helpful..

Concise and easy to read course materials, direct and to the point.

Learning about the audit process was helpful, and it's something that I can take back to my team.

It was very beneficial to pull actual records from my practice and perform an internal audit. It became very clear what areas of our medical record keeping need attention.

Upcoming Sessions

Pricing
Price: $119.00 USD This course is eligible for the 10% Multi-course discount. To learn more about the discount please visit the Multi-Course Discount page.

MEDICAL RECORDS: THE ROAD MAP TO QUALITY CARE

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