Lecture 4

Question 1

What is the purpose of a medical record?

Answer 1

• Medico-legal document recording animals’ history, diagnostics and treatments
• An evidential report for defence of a veterinarian for purposes of malpractice
• Communicative tool between vets for treating the same animal
• Record of recall to prompt treating vet
• A database for retrospective research and education

Question 2

What are the 8 components of a problem orientated medical record?

Answer 2

1. Signalment- species, breed, sex, age, neutered status
2. Reason for consultation
3. History as reported by owner (v.important if it is a completely new patient)
4. Physical exam- subjective (how patient looks) and objective (use the 10-body system approach) (using numbers in this part though)
5. Problem list- history, clinical findings, lab abnormalities
6. Assessment- examine each problem from the list and differential diagnosis (rule ins + outs)
7. Plan – diagnostic and treatment (what you want to do and why you want to do it, it needs to be specific what you are giving and why)
8. Progress notes (including client communication + consent to plan)

Question 3

What are the 10 different important body systems to cover in a medical history?

Answer 3

• Temp, Pulse, Resp. rate, mm, crt, hydration, BCS, weight.
• Ear, Eyes, Nose, Throat (EENT)
• Peripheral Lymph Nodes (PLN)
• Heart sounds
• Lung sounds
• Abdominal palpation (including rectal findings)
• Urogenital (UG)
• Skin
• Musculoskeletal (MSK)
• Neurological