Page 58 - Zoo Animal Learning and Training

42 Tasks for the Veterinary Assistant

utilizing a client list that is cross‐indexed, alphabetized with the animal and what has been done up to this time.
last name, and first name with the client number. So, you The chronologic history is more time consuming because
can see paper files take a great deal of effort to assemble there is no set order in which it is written so a veteri­
and file, so they can be retrieved again when needed. narian will have to read the entire entry to be able to
follow the history of the animal.
Ancillary information can also be included on a paper
Chronological Order or SOAP File file. It can indicate at a glance is if the animal is a biter. A
Format red star or tab on the front cover or a red tab placed on
the opposite corner from the letter or number tabs can
Some paper files will have colored tabs between the dif­ be an indication of this danger. There are also allergy
ferent sections of the record. Most will put the client/ stickers that can be placed on the folder to alert the staff.
patient data as the top page followed by the master Other ancillary information for paper history sheets
problem list, medication list, and immunizations page. could be in the form of stickers that have an outline of
Then there are two choices for the part of the file that the body or mouth. The mouth ones are used to indicate
contains the doctor’s notes about each visit and any issues with each tooth. The body sticker can indicate
other information about the animal; this is called the his­ where an animal has sores, lesions, bumps, or lumps on
tory. One type of history page is like a piece of notepaper. their body, with location and the size noted. Both are
The history is written in chronologic order as the veteri­ filled in as the examination is carried out on the animal.
narian thinks about the patient and all that needs to be This facilitates recheck visits to determine if the animal
done for the patient. It also includes medications that is recovering or getting worse.
were prescribed and any other notes as she/he thinks of If using a paper record it is important to make sure
them. This page is also used by the receptionist if the that all lab reports, radiographs, and other tests are
client called and a question was answered. Other staff marked in the file as they are completed. Otherwise,
members may also write on this page whenever something those things can get lost and there would be no indica­
was done to or for the animal if hospitalized. When the tion as to whether or not they had been carried out. This
page is full, another is placed on top. The second type of is unacceptable for two reasons. First, it could mean
history page is a bit more divided and will be in what is repeating tests that may be painful and costly. Second, if
called the SOAP format. This is a page which has specific the owner feels there has been a mistake made, sloppy
areas in which to write about the visit, phone call, or records could cast doubt on the quality of medicine a
other contact with the client/patient. Each letter of veterinarian practices and be grounds for a lawsuit,
SOAP stands for: which could cost the clinic money and possibly the vet­
erinarian’s license.
• Subjective information – client observations, the When pulling a paper file from the filing cabinet an
“chief complaint,” patient history as reported by the out‐guide is put in its place. This is usually larger than the
client and the physical aspect of the patient at the regular folder and is made of thicker cardboard. Some
time of visit.
• Objective data – veterinarian’s observations from the will have a space for the date the file was pulled upon it,
otherwise it is just used as a place marker to facilitate
physical exam, weight, and vital signs – in other words replacement.
the measurable data.
• Assessment – what the veterinarian has determined is
wrong, tentative, or differential diagnosis.
• Plans – where treatment protocols, medications, Reflection
diagnostic tests, procedures, or surgeries are written,
think of them as the “order” for the veterinary Compare and contrast the two ways to mark files:
technician and assistant to follow for the patient. the color‐coded numerical system versus the
Daily progress notes are listed here for hospitalized color‐coding alphabetizing last name system.
patients with entries concerning nursing care, eating,
drinking, and mentation. Follow‐up appointments
and prescribed drug therapies for the discharged
patient are written here too. Transferring Medical Records
There is usually one page per visit and they are kept in
the file in chronologic order with the most recent visit People move or decide to switch practices, or a client is
on top. This type of record works well when there is referred to a specialty practice and they require the
more than one doctor on staff. Different doctors can previous medical records. In all instances, a confidenti­
look in specific areas to find quickly what is going on ality waiver must be signed by the client before a copy or