Question

HIT 114 Chapter 14 Case Study You are the only health information management professional at a local veterinary clinic. On your first day of work, you quickly determine that there is a desperate need for organization of the health records for the animals. Currently, there is one paper-based health record for each family who has pets treated at this clinic. The staff appears to work well with the current system and claim that it is easier to use because most families bring in all their pets at the same time to be seen. How would you approach this topic with the veterinarians? What steps would you take or changes would you recommend to the veterinarian?

Answer 1

Maintaining healthcare records for animals & pets are very essential .These records are benchmarks and usually serves details about the animals,their condition,  type of infection, the treatment given , the outcome, types of vaccines administered, etc. These records help in easy retrieval of data of the particular pet and also serves as legal documents. Records also serves as a source for statistical data regarding the number of pet population and their necessities.

On the whole medical records are for safety of the patient , for safeguarding the doctor and staff in the clinic .There are two formats of organizing the medical file namely

• The source-oriented veterinary medical record :Medical information of pets /animals are entered in a sequential order .It is easy to write and learn , but it is difficult to retrieve the necessary detail in time . The record may be divided into several sections like complaints, treatment, laboratory investigations, diagnostics,etc. A medical problem of an individual may be difficult to monitor as the record may not be in detailed format and hard to locate easily. It is a primary document.
• The problem-oriented veterinary medical record : This record is an organised one ,because each problem is assigned a separate number and marked individually.SOAP note is written for each problem in the record. This record facilitates good communication and helpful in diagnosing appropriately with necessary care & cure. This record also helps in follow up . This medical record is a well organised one.

I would explain the veterinarians about the necessity for medical records, that it serves as a legal document and also serves as an eye opener for the improvement of the facility. The records help to identify and prioritize problems, and formulate an understanding of the patient's reactions to an illness and also to find a exact cure for it. So a clinical facility should have an organised medical record system for improving quality of facility and care.Thus all veterinarians and healthcare staffs should be educated about the needs and necessity of an organised medical record in the facility. They also should be given training about how to maintain medical records and databases. HIM department should be started in the facility .