Deck 2: Medical Records

Question 1

Progress notes are recorded in __________ order in the medical record.

Answer 1

chronological

Question 2

Place one single line through any error made in the medical record and then correct and _________ the mistakes.

Answer 2

initial

Question 3

Which statement about recording information on the medical record is NOT true?

A) Medical records are legal documents
B) Do not try to erase or obliterate an error entry
C) Stamps and stickers should not be used on medical records because they ae legal documents
D) All entries are written in dark ink, either blue or black

Answer 3

Stamps and stickers should not be used on medical records because they ae legal documents

Question 4

How many years are many states required to keep medical records?

A) 10 years
B) 7 years
C) 5 years
D) 3 years

Question 5

Where is the SOAP recording method commonly used?

A) vaccine records
B) consent form
C) master problem list
D) progress notes

Question 6

The ________ details a patient's past surgeries, medical conditions, and vaccines.

Question 7

Which of the following statements about filing medical records is NOT true?

A) A color that is our of order is easier to identify than either numbers or letters that are out of order
B) Because no one is perfect, owners are sympathetic when thier records have been misfiled
C) Numeric filing requires a way to cross-reference the client's name with the client's file number
D) More misfilies occur with alphabetical filing

Question 8

Which of the following filing methods is most commonly used in a veterinary facility?

A) numerical filing
B) alphabetical filing
C) color coding
D) free filing

Question 9

The health certificate must include vaccine dates of an animal.

Question 10

When discharging a client and patient, which is NOT necessary for the veterinary assistant to check?

A) that discharge instructions are clear
B) that client has all of the prescribed medications
C) that the client has made a follow up appointment, if necessary
D) the veterinary assistant should check all of the above

Question 11

Never write in pencil when recording in a veterinary medical record.

Question 12

In the SOAP format for progress notes, in which category would the chief complaint be written?

A) subjective information
B) objective information
C) assessment
D) plan or procedure

Question 13

Which of the following is a DO when recording in a medical record?

A) erase all errors
B) write illegibly
C) place a single line through errors
D) use common language

Question 14

The veterinary-client-patient relationship or VCPR must be maintained legally within 2 years.

Question 15

The veterinary assistant must record an animal's history, but it is not necessary to note any communications with the client by phone or verbally within the medical record.

Question 16

The temperature and heart rate of an animal is an example of __________ information.

A) subjective
B) objective
C) assessment
D) plan

Question 17

Which of the following statements is TRUE about the confidentiality of medical records?

A) The only time information can be shared is for the purpose of patient care.
B) It is okay for the information to be shared with anyone associated with the hospital.
C) It is okay to share information with your family members.
D) Veterinary medical records are not confidential, only human medical records are confidential.

Question 18

Which of the following vaccines is legally required to be given to some animal species?

A) distemper vaccine
B) feline leukemia vaccine
C) lyme vaccine
D) rabies vaccine

Question 19

Who owns the physical medical record?

A) the client
B) the patient
C) the state
D) the veterinary practice

Question 20

Each letter of the alphabet label is assigned an individual __________.

Question 23

The __________ is the reason the veterinarian is seeing the patient during an appointment.

Question 32

Match the following terms with the correct definition.
Errorrr

A) measured facts based on an animal
B) the animal seen by the facility
C) detailed information written about each animal
D) identifies procedures to the owner and allows the owner to authorize them
E) vet's diagnosis of an animal's problem
F) proof of a spay or castration surgery
G) treatment or procedure given to an animal
H) log entries made of each treatment
I) opinion of animal's appearance and attitude
J) form to allow an animal to travel
K) relationship between vet and animal owner
L) the owner of an animal
M) method of filing medical records

Question 33

Match the following terms with the correct definition.
Errorrr

A) measured facts based on an animal
B) the animal seen by the facility
C) detailed information written about each animal
D) identifies procedures to the owner and allows the owner to authorize them
E) vet's diagnosis of an animal's problem
F) proof of a spay or castration surgery
G) treatment or procedure given to an animal
H) log entries made of each treatment
I) opinion of animal's appearance and attitude
J) form to allow an animal to travel
K) relationship between vet and animal owner
L) the owner of an animal
M) method of filing medical records

Question 34

Match the following terms with the correct definition.
Errorrr

A) measured facts based on an animal
B) the animal seen by the facility
C) detailed information written about each animal
D) identifies procedures to the owner and allows the owner to authorize them
E) vet's diagnosis of an animal's problem
F) proof of a spay or castration surgery
G) treatment or procedure given to an animal
H) log entries made of each treatment
I) opinion of animal's appearance and attitude
J) form to allow an animal to travel
K) relationship between vet and animal owner
L) the owner of an animal
M) method of filing medical records