History and Physical Examination Part X: The Medical Record Mr. Robinson edrobinson02@sbcglobal.net

The Medical Record The medical record is a legal document that belongs to the veterinary clinic, hospital or owner of the practice. The records do not belong to the client. While the client has a right to copy of the records, the owner has no right to the original medical record. Every time the vet sees an animal, performs a test, or communicates by phone, someone records the information in the medical record. This means that anything pertinent to the animal’s current medical condition, medical history, or anything medical is documented. This protects the animal, owner and vet/vet practice as long as the medical record is complete, current and accurate. There are several different parts to the medical record: Owner information (identity and contact information) Animal information (name, species, breed, color, sex, and age or date of birth) Dates of vaccination Assessment of symptoms Lab reports Diagnoses Prognoses (outlook for the patient) Home care instructions (copies of originals go to the owner) These are typical parts of the medical record and there is often times more information as well.

Medical Record Organization The medical record must be legible and orderly. The vet or practice will determine in what order the record will be assembled. While the order of the record will vary from clinic to clinic, it should be consistent within the clinic. The most typical types of records are full page records with 8 ½ X 11 inch paper pages, card format with 5 X 8 inch cards or paperless computer records. The full page record can be fastened inside a medical record folder or folded in half and placed inside a record envelop. Paperless computer records are becoming more and more popular as practices spread out into new technologies. The drawback is that the record needs to be printed for each visit if a computer is not available in each exam room. Also, the records need to be backed up daily in case of a power outage or other computer catastrophe occurs. The back ups should be kept in a fireproof safe or off the premises for insurance against loss.

The information can be kept in a problem-oriented fashion or by visit. The medical record is usually kept in reverse chronological order, meaning the most current information is on top with the older entries at the back. The information can be kept in a problem-oriented fashion or by visit. In other words, each visit has an entry for each problem the animal has. Or, there can be one full entry that includes all problems. Problem oriented example: Cc: scratching rear, shaking head, eye discharge There will be a SOAP (more on this in a minute) for each problem. SOAP for scratching SOAP for shaking head SOAP for eye discharge

The 1st page of the medical record usually contains owner and patient information, vaccination history and a master problem list (list of problems treated or diagnosed). No matter how the record is set up, each entry for each visit is set up in the same basic format. The appearance may be different from clinic to clinic but the basic information is still the same. The SOAP format is used by all clinics in one form or another.

SOAP Format SOAP is an anachronym that stands for: S = Subjective O = Objective A = Assessment P = Plan or Procedure This anachronym forms the Progress Notes portion of the medical record where all information for each visit is recorded. Not all clinics use the SOAP format in its traditional format, but all records can be read and placed in this basic format.

Subjective Subjective data is based on observation and unquantified information. Essentially, this is the information that the client gives you. It also includes any information you collect that cannot be measured or repeated. EX: vomiting/diarrhea/limping/depression, etc These things are seen but may not be able to be reproduced or measured by someone else. These observations and information are recorded in the S (subjective) section. They can be further broken down to client complaint, History, PE, etc. Ex: S = cc: vomiting/diarrhea Hx: vomiting 2x daily for 3 days, Watery diarrhea for 5 days, and any other history. PE: physical exam results that are observational.

Objective Objective data is measurable or reproducible. This is section measurable parts of the PE are recorded (ex: temperature, weight, heart rate, respiratory rate, capillary refill time, etc). Also, lab results are recorded here. The technician can record information in the S and O areas of the medical record.

Assessment Assessment data of the progress notes are used to record possible diagnoses or diagnostic rule outs. It also includes the prognosis of the patient.

Plan or Procedure Plan or Procedure data is used to outline the plan for treatment. It includes any problems that need to be monitored, follow up care, medications, and other recommendations. The A and P sections are for vet use only. A technician should never write in the assessment or plan section unless the doctor is dictating the information to the technician. It will take practice to use the SOAP format correctly.

SOAP Case #1 Differential Diagnosis (DDx): flea allergic dermatitis, food allergy, contact allergy, airborne allergy. Rx: Advantage once monthly. Prednisolone 5mg #8 Give 1 tab BID for 2days then give 1 tab SID for 2 days, then give ½ tab SID for 2 days, then give ½ tab EOD for 4 days. CC: Scratching and irritation on the abdomen with sores for 4 days. PE: skin-redness and abrasions over ventral abdomen. Hair loss over cranial, ventral abdomen. Other systems WNL.

TX: Apply Advantage for fleas Fecal = neg Skin scrape = neg Hx: scratching for 2 weeks but worse in last 4 days. On flea control in form baths and dips every 4 weeks. No changes to the diet in last year. No other problems noted. TX: Apply Advantage for fleas Give steroids for scratching Reassess in 2 weeks if no better in 2 weeks or starts up within next 2 months recommend skin allergy testing to rule out airborne and contact allergies, if negative: recommend food trial to rule out food allergies.

Weight = 25#, HR = 80bpm, RR = 20bpm, CRT<1sec, Temp = 101.3

SOAP Format S: CC: Scratching and irritation on the abdomen with sores for 4 days. Hx: Scratching for 2 weeks but worse in the last 4 days. On flea control in the form of baths and dips every 4 weeks. No changes to the diet in the last year. No other problems noted. PE: skin-redness and abrasions over ventral abdomen. Hair loss over cranial, ventral abdomen. Other systems WNL.

O: Weight = 25#, HR = 80bpm, RR = 20bpm, CRT< 1 sec, Temp = 101.3 Fecal = neg Skin scrape = neg A: Differential Diagnosis (DDx): Flea allergic dermatitis, food allergy, contact allergy, airborne allergy. P: Tx: Apply Advantage for fleas Give steroids for scratching Reassess in 2 weeks if no better in 2 weeks or starts up again within 2 months recommend skin allergy testing to rule out airborne and contact allergies, if negative: recommend food trial to rule out food allergies. Rx: Advantage once monthly Prednisolone 5mg #8 Give 1 tab BID for 2 days, then give 1 tab SID for 2 days, then give ½ tab SID for 2 days, then give ½ tab EOD for 4 days.

SOAP Case #2 Hx: Diarrhea for 3 days, vomiting for 2 days, not eating for 3 days. No history of getting into garbage. Tx: IV fluids LRS 100ml/hr for 12 hours then 50ml/hr Ampicillin 200mg IV TID Tagamet 5mg IV TID PE: Gastrointestinal-signs of diarrhea on rectum, redness around rectum. No gas distension upon palpation. Skin Turgor Pressure = 5 seconds.

CC: vomiting/diarrhea and anorexia Vomited yellow liquid on exam room floor. Wgt = 75#, HR = 120bpm, RR = 40bpm, CRT < 2sec, Temp = 102.9° DDx: kidney failure, intestinal obstruction, liver disease, intestinal parasites. Fecal = neg X-rays = no foreign bodies seen in intestinal tract.

Plan: IV fluids LRS 100ml/hr for 12 hours then 50ml/hr Ampicillin 200mg IV TID Tagamet 5mg IV TID Monitor Temp BID Chemistry Profile and CBC Repeat fecal Diagnosis: vomiting and diarrhea with 5% dehydration and anorexia. R/O kidney and liver disease, parasites, and inappropriate diet. No apparent obstruction.

S: CC: vomiting/diarrhea and anorexia Hx: Diarrhea for 3 days, vomiting for 2 days, not eating for 3 days. No history of getting into the garbage. PE: Gastrointestinal- signs of diarrhea on rectum, redness around rectum. No gas distention upon palpation. Skin turgor pressure = 5 seconds. Vomited yellow liquid on exam room floor

O: Wgt = 75#, HR = 120bpm, RR = 40bpm, CRT < 2sec, Temp = 102.9° Fecal = neg X-rays = no foreign bodies seen in intestinal tract. A: Diagnosis: vomiting and diarrhea with 5% dehydration and anorexia. R/O kidney and liver disease, parasites and inappropriate diet. No apparent obstruction. DDx: kidney failure, intestinal obstruction, liver disease, intestinal parasites.

P: Plan: IV fluids LRS 100ml/hr for 12 hours then 50ml/hr Ampicillin 200mg IV TID Tagamet 5mg IV TID Monitor Temp BID Chemistry Profile and CBC Repeat fecal Tx: IV fluids LRS 100ml/hr for 12 hours then 50ml/hr

SOAP Case #3 CC: seems painful, not eating, vomiting 2x daily for 3 days. Wgt = 35#, Temp = 103.5°, HR = 150bpm, RR = 80bpm, CRT < 2 sec. Tx: IV fluids 20ml/hr, Normosol w/5% dextrose NPO for 2 days then offer small amounts of ID diet Torbugesic 5mg SQ QID Gentamycin 50mg IV BID Ampicillin 200mg IV TID Monitor for vomiting and temperature

Chemistry: Lipase = 1015, Amylase = 3525 Assess: painful in abdomen around pancreas Unable to palpate due to pain. Chemistry profile shows marked increase in pancreatic enzymes Dx: acute pancreatitis Plan: Hospitalize on fluids, NPO for 2 days then offer small amounts of ID diet and monitor temperature and vomiting. Give antibiotics for fever and analgesics for pain. PE: Gastro-painful, splinted abdomen around cranial abdomen. All other systems WNL Hx: painful and anorexic past 2 days, vomiting for 3 days, lethargic and depressed for 2 days.

S: CC: seems painful, not eating, vomiting 2x daily for 3 days. Hx: painful and anorexic past 2 days, vomiting for 3 days, lethargic and depressed for 2 days. PE: Gastro-painful, splinted abdomen around cranial abdomen. All other systems WNL O: Wgt = 35#, Temp = 103.5°, HR = 150bpm, RR = 80bpm, CRT < 2 sec. Chemistry: Lipase = 1015, Amylase = 3525

A: Assess: painful in abdomen around pancreas Unable to palpate due to pain. Chemistry profile shows marked increase in pancreatic enzymes Dx: acute pancreatitis P: Plan: Hospitalize on fluids, NPO for 2 days then offer small amounts of ID diet and monitor temperature and vomiting. Give antibiotics for fever and analgesics for pain. Tx: IV fluids 20ml/hr, Normosol w/5% dextrose NPO for 2 days then offer small amounts of ID diet Torbugesic 5mg SQ QID Gentamycin 50mg IV BID Ampicillin 200mg IV TID Monitor for vomiting and temperature

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