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Chapter 3 Veterinary Business Protocols 41

Paper Patient Record Assembly shape or form. One method is to use colored tabs to rep­
resent the letters of the alphabet. The first three letters
It is prudent to have blank medical records prepared in of the last name are placed on the file edge, then the
advance of new client appointments. Even if utilizing client’s full name is written along side the tabs
management software you will need their information to (Figure 3.2). The file is placed in the file cabinet in
fill in the database. This accomplishes two things: avoid­ alphabetical order. Remember, if you have several
ing a failure to include all pertinent information and Smiths, Jones, or Andersons, alphabetize using the first
making the client wait while the forms are found and put name, and if more than one John use the middle initial.
together on a clipboard. The clipboard is given to all This is often where things go wrong, and files get mis­
new patients to fill out and return. The first form con­ filed because someone doesn’t know their alphabet!
tains the database information already covered in the
admitting patient section. The second page will be the
consent forms which are discussed after this section.
Once everything is completed and returned, place the
information into the management software program or
if using paper records assemble the sheets into the file
shell.
There is usually a specific order in which the clinic
likes to have their client records organized in the file
shell. It is a good idea for you to learn that order and if
in doubt look at other files or ask before assembling or
adding more sheets. FIGURE 3.2 Color‐coded file: alphabetical.
The file shell is usually a manila folder which is often
divided into sections. The top section is the client data­ A second method is to assign the client a number; this
base form followed by a page that lists the master prob­ can be generated by the next number in line. The file
lems, medications, immunizations, and lab or test results. folder is marked with tabs that are a different color for
A colored divider may used between sections to separate each number from 0 to 9. Most systems will start with
the consent forms from the history sheets. 100, as three tabs are easier to see a color pattern than
For established clients, the file is pulled from the fil­ two or fewer. The client’s name is written on the tab
ing cabinet and the database information is reviewed to either alongside or under the numbers (Figure 3.3).
make sure it is correct, corrections are made if necessary,
and the reason for the visit is marked on the planning
section. Always check to make sure there is room for this
visit’s notes to be entered into the file. If in doubt add
another sheet in the proper order as dictated by the clin­
ic’s procedure.
Once the file has been checked over, it can be placed
in a designated area indicating that the client has arrived
and is ready to be seen.

Reflection FIGURE 3.3 Color‐coded file: numerical.

What possible advantage would organizing all Both schemes make it easy to find files. If a client has
paper records in exactly the same way give the more than one animal, each should have its own file
practice? folder. In this case, the name of the pet is placed behind
or under the client’s name, so you don’t have to open
every one to find the right pet.
These color‐coding systems are touted as foolproof
Paper Filing Systems for not losing a file. However, it still takes time to find
one if they are alphabetized incorrectly, especially if you
The retrieval of paper records is a bit more involved than are dealing with common last names like Smith, Jones,
the computerized version. There are many filing systems or Anderson and first names of Bob, Tom, Mary, or Beth.
available and they all involve alphabetizing the client list An issue with the numbering system is that clients often
by last name, first name, and middle initial in some do not remember their client number. This is covered by