EXAMPLES OF PROPER MEDICAL RECORD KEEPING This workforce solution was funded by a grant awarded under the President’s Community-Based Job Training Grants as implemented by the U.S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. This solution is copyrighted by the institution that created it. Internal use by an organization and/or personal use by an individual for non-commercial purposes is permissible. All other uses require the prior authorization of the copyright owner.

Name___Molly_________ Breed__Beagle__________ Species____Canine_______ Gender___F(s)_________ ID #___USDA tag #2346___________ Age (DOB)____ _____ Source_____USDA class B vendor_______

Entry 1 Entry Per Dr. DoLittle, administered 250 mg Cephalexin (250mg/capsule) PO one time. H. Wipijewski Per Dr. DoLittle, administered 250 mg Cephalexin (250mg/capsule) PO one time. H. Wipijewski

Let’s review the previous entry. Let’s review the previous entry Per Dr. DoLittle, administered 250 mg Cephalexin (250mg/capsule) PO one time. H. Wipijewski Per Dr. DoLittle, administered 250 mg Cephalexin (250mg/capsule) PO one time. H. Wipijewski We have the date, the name of the medication, how much medication we gave, the route we gave it, how often we gave it and our name. We have the date, the name of the medication, how much medication we gave, the route we gave it, how often we gave it and our name.

Example 2 Example – Took ear swab from AU. H. Wipijewski – Took ear swab from AU. H. Wipijewski

Was this an adequate entry? Was this an adequate entry? NO! NO! What information is missing? What information is missing?

– Took ear swab from AU. H. Wipijewski – Took ear swab from AU. H. Wipijewski The description of what we found in the ears is missing. The description of what we found in the ears is missing – Took ear swab from AU. Small amount of light brown debris noted AU. H. Wipijewski – Took ear swab from AU. Small amount of light brown debris noted AU. H. Wipijewski

Now it’s your turn. You have blank copies of a medical record in front of you. Enter the following information into the appropriate spots. Now it’s your turn. You have blank copies of a medical record in front of you. Enter the following information into the appropriate spots.

You are working in a research facility and a new dog comes in. You need to fill out the appropriate medical record. There is no name for the dog at this time, but the ID# on its’ tag is She’s a basset hound who is approximately 3 years old and is not spayed. She arrived from a USDA vendor named Mr. Doe. You are working in a research facility and a new dog comes in. You need to fill out the appropriate medical record. There is no name for the dog at this time, but the ID# on its’ tag is She’s a basset hound who is approximately 3 years old and is not spayed. She arrived from a USDA vendor named Mr. Doe. Fill in the above information in the appropriate location on the record. Fill in the above information in the appropriate location on the record.

As soon as this dog came in, Dr. X did a physical exam and noted that there were no abnormalities. He would like for you to weigh this dog and administer 100mg of Amoxicillin (200mg/tablet) orally once. As soon as this dog came in, Dr. X did a physical exam and noted that there were no abnormalities. He would like for you to weigh this dog and administer 100mg of Amoxicillin (200mg/tablet) orally once. Document the above information in the medical record. Document the above information in the medical record.

The entry should look like this: – Weight – 30.5 pounds. Per Dr. X, administered 100mg of Amoxicillin (200mg/tab) PO one time. H. Wipijewski How many tablets did we just administer to this dog?

Let’s try another entry. Let’s try another entry. You read on the status board that Dr. X would like the dog with ID# 5467 to be observed twice daily during feeding time to note behavior and attitude towards the food. You feed her and sit down to watch what she does. You notice that she begins to paw at the food and attempt to bury it. This is something that she has done numerous times before. She proceeds to eat all of her food. You didn’t see anything that you thought was unusual. You read on the status board that Dr. X would like the dog with ID# 5467 to be observed twice daily during feeding time to note behavior and attitude towards the food. You feed her and sit down to watch what she does. You notice that she begins to paw at the food and attempt to bury it. This is something that she has done numerous times before. She proceeds to eat all of her food. You didn’t see anything that you thought was unusual.

What do you write in the record? Do you write anything down? What do you write in the record? Do you write anything down? YES! YES! Although you don’t think that you saw any unusual behavior, if you don’t write anything in the record, Dr. X may think that you didn’t observe her. Although you don’t think that you saw any unusual behavior, if you don’t write anything in the record, Dr. X may think that you didn’t observe her. What do you write in the record? What do you write in the record?

– Observation during afternoon feeding. No abnormal behavior noted – Observation during afternoon feeding. No abnormal behavior noted. Is this appropriate? Is this appropriate? NO! NO! We should describe what we did see. Although it may be typical for her, we still need to document what she did. We should describe what we did see. Although it may be typical for her, we still need to document what she did. What else is missing? What else is missing?

– Observation during evening feeding. Noted that she attempted to bury the food. Ate entire meal (1/2 cup) H. Wipijewski – Observation during evening feeding. Noted that she attempted to bury the food. Ate entire meal (1/2 cup) H. Wipijewski The initials were also missing from the first entry. The initials were also missing from the first entry. Be as descriptive as you can. Be as descriptive as you can.

Let’s try to correct an entry. Let’s try to correct an entry. Here’s the entry: Here’s the entry: – Observation during morning feeding. Fed 1.0 cup of dog food. Ate approximately ½ cup. Proceeded to vomit a small amount, 45 minutes after eating. Vomit consisted of undigested food. Cleaned cage. H. Wipijewski – Observation during morning feeding. Fed 1.0 cup of dog food. Ate approximately ½ cup. Proceeded to vomit a small amount, 45 minutes after eating. Vomit consisted of undigested food. Cleaned cage. H. Wipijewski

After you make your entry, you realize you meant to write evening feeding instead of morning feeding. After you make your entry, you realize you meant to write evening feeding instead of morning feeding. How do we correct this entry? How do we correct this entry?

hw – Observation during morning (change to evening) feeding. Fed 1.0 cup of dog food. Ate approximately ½ cup. Proceeded to vomit a small amount, 45 minutes after eating. Vomit consisted of undigested food. Cleaned cage. H. Wipijewski – Observation during morning (change to evening) feeding. Fed 1.0 cup of dog food. Ate approximately ½ cup. Proceeded to vomit a small amount, 45 minutes after eating. Vomit consisted of undigested food. Cleaned cage. H. Wipijewskimorning 1. wrong time of day 1. wrong time of day

REVIEW When making an entry, be sure to include the date! When making an entry, be sure to include the date! Be sure to be COMPLETE with your entry. Be sure to be COMPLETE with your entry. Be as descriptive as you can. Be as descriptive as you can. Initial! Initial! Remember that medical records are legal documents! Remember that medical records are legal documents! Correct errors in the appropriate manner. Correct errors in the appropriate manner.