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Analyze proper usage of veterinary practice management procedures
Essential Standard 1.00
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Understand the proper veterinary terminology to accurately describe and record medical conditions
Objective 1.01
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Veterinary Medical Terminology
Based on Latin and Greek words Material taken from Veterinary Assisting: Fundamentals and Applications chapter 1
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Dissecting a Term Dissect or separated them to define their meanings
Prefix is at the beginning of the word Root word gives the team its essential meaning. A term may have more than one root word. Suffix is at the end of the word Combining vowel allows for certain terms to be pronounced more easily. Usually the letter “o” but can be any vowel. Common Root Words
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Root Meaning Arthr/o- Joint Cardi/o- Heart Chem/o- Chemical Col/o- Colon Cutane/o- Skin Cyst/o- Urinary bladder Dent/o- Teeth Electr/o- Electricity Enter/o- Intestines Gastr/o- Stomach Hem/o- Blood Hepat/o- Liver Hyster/o- Uterus Lapar/o- Abdomen
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Mast- Mammary gland Nas/o- Nose Nephr/o- Kidneys Oste/o- Bone Ovari/o- Ovary Radi/o- Radiation Rect/o- Rectum Rhin/o- Urin/o- Urine Uter/o- Uterus
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Suffixes Meaning “Pertaining To”
Term Meaning -ac Cardiac Pertaining to the heart -al Renal Pertaining to the kidney -an Ovarian Pertaining to the ovary -ar Lumbar Pertaining to the loin or lower back -ary Alimentary Pertaining to the gastrointestinal tract -eal Laryngeal Pertaining to the larynx -ic Enteric Pertaining to the intestines -ine Uterine Pertaining to the uterus -ous Cutaneous Pertaining to the skin -tic Nephrotic Pertaining to the kidneys
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Common Prefixes Prefix Meaning Example Definition a- or an-
Without; no Anemia Without or no blood cell production Ab- Away from Abduction Away from the center o the body Ad- Toward Adduction Toward the center of the body Anti- Against; to stop Anticoagulant Medicine used to stop bleeding Dys- Difficult; painful Dysuria Difficult or painful urination Ecto- Outside Ectoskeleton Bones located outside the body Endo- Within, inside Endothermic Body temperature controlled within the body Exo- Exothermic Body temperature controlled outside of the body Hyper- Above normal Hyperglycemia High blood sugar Hypo- Below normal Hypoglycemia Low blood sugar
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Common Prefixes Continued
Inter- Between Interdigital Between the toes Intra- Within Intramuscular Within the muscles Oligo- Very little Oliguria Very little urine production Peri- Around Perioperative Around or during the surgery Poly- Many, excessive Polyuria Excessive urine production Post- After Postoperative After the surgery Pre- Before Preanesthetic Before anesthesia Sub- Below Subcutaneous Below the skin Super- Above Superimposed Above the surface
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Common Suffixes Suffix Meaning Example Definition -centesis
Surgical puncture into Cystocentesis Surgical puncture with a needle into the urinary bladder -ectomy Surgical removal of Ovariohysterectomy Surgical removal of the ovaries and uterus -emia Blood Hypocalcemia Low blood calcium -gram A record of Electrocardiogram A record of the electrical activity of the heart -graph To record with an instrument Radiograph A record made using radiation; x-ray -graphy The act of recording using an instrument Radiography The act of taking a picture using radiation -itis Inflammation Colitis Inflammation of the colon -logy The study of Histology The study of tissues -lysis To break down Urinalysis The breakdown of urine into parts -megaly Enlargement of Cardiomegaly Enlargement of the heart -osis Condition Osteoporosis Condition of bone loss
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Common Suffixes Continued
-pathy Disease Cardiopathy Heart disease -pexy To suture to Gastropexy To suture to the stomach -plasty To surgically repair Rhinoplasty Surgical repair of the nose -rrhage- To burst Hemorrhage The bursting of the blood; bleeding -rrhea- To flow Diarrhea The flow of feces -scope Instrument used to view Microscope Instrument used to view small items -scopy The act of using an instrument for viewing Endoscopy The act of using a scope to view the inside of the body -stomy To create a new surgical opening Cystostomy To create a new surgical opening in the urinary bladder -therapy Treatment Chemotherapy Treatment of chemicals -tomy To cut into surgically; to make an incision Cystotomy To make an incision into the urinary bladder
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Putting it all together
When dissecting a term use a slash mark to divide the term Examples: arthr/itis inflammation of the joint cardio/logythe study of the heart cardio/megaly enlargement of the heart
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Common Directional Terms
Meaning Aspect Area Caudal Toward the tail Cranial Toward the head Distal Away from the center of the body Dorsal Toward the back area Lateral Side of the body; toward the outside Medial Inside of an area; toward the inside Palmar The bottom of the front feet Plantar The bottom of the rear feet Proximal Closer to the center of the body Recumbency Lying in position Recumbent Lying Rostral Toward the nose Traverse Across an area dividing it into cranial and caudal sections Ventral Toward the abdomen or belly area
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Veterinary Terms and Abbreviations
Species Terms Amphibian- frog/toad Avian- bird Bovine- cow Canine- dog Caprine- goat Cavy- guinea pig Equine- horse Feline- cat Lagomorph- rabbit Murine- rat or mouse Ovine- sheep Porcine- pig or swine Poultry- chicken and turkey Primate- monkey and ape Reptile- snake and lizard Terrapin- turtle
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Term Definition Bitch Intact female dog Litter Group of newborn dogs Puppy Young dog Stud dog Intact male dog Whelping The labor process of dogs Kitten Young cat Tom Intact male cat; male turkey Queen Intact female cat Queening The labor process of cats Buck Male rabbit; male goat; male deer Doe Female rabbit; female goat; female deer Kindling Labor process of rabbits and ferrets Kit Young rabbit; young ferret Lapin Neutered male rabbit Gib Neutered male ferret Hob Intact male ferret Jill Intact female ferret Sprite Neutered female ferret Boar Male guinea pig; male pig Pup Young guinea pig; young mouse; young rat; young dog Sow Female guinea pig; female pig Dam Female rat; female mouse; term for a female parent that is breeding
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Sire Male rat; male mouse; term for a male parent that is breeding Chick Young parrot; young chicken Cock Male parrot; male chicken Flock Group of birds; group of chickens, turkeys or ducks Hen Female parrot; female chicken; female turkey Clutch Group of eggs Poult Young turkey; young chicken Capon Young castrated male chicken Cockerel Immature male chicken Pullet Immature female chicken Rooster Male chicken Drake Male duck Duck Female duck Duckling Young duck Barrow Young castrated male pig
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Term Definition Farrowing Labor process of swine Gilt Young female pig that has not farrowed Piglet Young pig Stag Male pig castrated after maturity Colt Young male horse Filly Young female horse Foal Young male or female horse Gelding Castrated male horse; castrated male llama Hand The measurement of a horse equal to 4 inches Herd Group of horses Horse Horse over 14.2 hands in height Mare Intact female horse Pony Horse under 14.2 hands Stallion Intact adult male horse Weanling Young horse under a year of age Yearling Young horse between the ages of 1 and 2 years Donkey Donkey crossed with a donkey Hinny Cross of a male horse and a female donkey Jack Intact male donkey Jenny Intact female donkey Mule Cross of a male donkey and a female horse Ewe Intact female sheep
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Lamb Young sheep Lambing Labor process of sheep Ram Intact male sheep Wether Castrated male sheep; castrated male goat Freshening Labor process of dairy-producing animals Kid Young goat Kidding Labor process of goats Bull Intact male cow; intact male llama Cow Intact female cow; intact female llama Cria Young llama Calf Young cow Calving Labor process of cows Heifer Young female cow that has not been bred Stag Mature castrated male cow Steer Young castrated male cow
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Common Veterinary Abbreviations
C or cast- castrated C-sect- C-section or caesarian section d- day d/c-discharge DLH- domestic long hair (cat) DSH- domestic short hair (cat) d/o-drop off EX-exotic F- female K-9-dog or canine M-male Mo-month NM-neutered male o-owner p/u-pick up rec-recommend S or SF- spayed or spayed female S/R- suture removal Sx- surgery Wk-week Y or yr- year
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Terms related to Patient History
Anorexia- not eating or decreased appetite BM- bowel movement D- diarrhea Dysuria-difficulty or trouble with urination Dz- disease HBC- hit by car Hematuria- blood in the urine Hx- history Lethargic-tired or inactive PD-polydipsia (increased thirst) PU-polyuria (increased urination) U-urine V-vomiting V/D-vomiting and diarrhea
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Terms Related to Physical Examination
Acute-short term Anals or AG- anal glands BAR- bright, alert, responsive CHRONIC- long term CRT- capillary refill time Dx- diagnosis FeLV- feline leukemia virus FIP- feline infectious peritonitis FIV- feline immunodeficiency virus HR- heart rate L- left LN- lymph node mm- mucous membranes N or [-] negative NR- nothing reported
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Terms Related to Physical Examination
NSF- no signs found PE- physical exam Px- prognosis QAR- quiet, alert, responsive R- right RR- respiratory rate Rx- prescription SOAP- Subjective, Objective, Assessment, Plan TPR- temperature, pulse, respiration Tx- treatment URI- upper respiratory infection UTI- urinary tract infection WNL- within normal limits Wt- weight + positive
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Laboratory Terms and Abbreviations
Bx- biopsy CBC- complete blood count CHEM- blood chemistry panel C/S or C&S- culture and sensitivity Cysto- cystocentesis Fecal- fecal or stool sample HW- heart worm PCV- packed cell volume T4- thyroid test UA- urinalysis
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Pharmacy Terms and Abbreviations
BID- twice a day Cap- capsule cc- cubic centimeter d- day EOD- every other day h- hour kg- kilogram mg- milligram ml- milliliter NPO- nothing by mouth
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Pharmacy Terms and Abbreviations
oz- ounces PO- by mouth prn- refill as needed (per required need) q-every qd-every day QID- four times a day Rx- prescription SID- once a day Tab- tablet
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Pharmacy Terms and Abbreviations
TID- three times a day w-week / -per # or lb- pound #- number of tablets to dispense
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Eyes and Ears AD- right ear AS- left ear AU- both ears OD- right eye
OS-left eye OU- both eyes
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Routes of Medical Administration
Adm.- administer IC- intracardiac (into the heart) ID- intradermal (within the layers of skin) IM- intramuscular (into the muscle) IN-intranasal (into the nasal cavity) IO- intraosesous (into the bone) IP- intraperitoneal (into the peritoneum or lining of the abdomen) IT- intratracheal (into the trachea or windpipe) IV- intravenous (into the vein) PO- by mouth or orally SQ or SUB-Q- subcutaneous (under the skin)
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Association Abbreviations
AAHA- American Animal Hospital Association AVMA- American Veterinary Medical Association NAVTA- National Association of Veterinary Technicians in America TVMA- Texas Veterinary Medical Association OFA- Orthopedic Foundation of America
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Analyze methods to correctly maintain veterinary medical records
Objective 1.02
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Purpose of Medical Records
Purpose: to provide information for each veterinarian and serves as a diary of an animal’s health that is helpful in multiple doctor facilities and to transfer records. A. It includes: Patient Client (animal owner) Patient history Medical/Surgical records Progress notes Lab information B. The medical record is owned and is the property of the veterinary facility 1- serves as a legal document that is private and confidential 2- allows for the Veterinary-Client-Patient-Relationship (VCPR) to be established which provides the opportunity for the veterinarian to make judgments regarding health, diagnosis, how to provide care, and the way records are maintained 3- must remain in the facility for 1-3 years although many hospitals keep records for 7 years after last visit
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Creating a Medical Record
File should include the following sections or forms: Client and patient information Master problem list with details of a patient’s history and previous medical problems, vaccines or surgeries When writing the medical record also make a cage card to identify and locate each patient After treatment is recommended by the veterinarian an estimate sheet will be prepared with costs listed Treatment will b reviewed with the client and consent forms signed Care will also be reviewed with the client so the owner can continue to medicate and care for the patient The invoice should be placed on top for easy access for all in the veterinary clinic
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Recording the Information in the Medical Record
All information must be recorded in blue or black ink (NEVER in pencil or other ink colors) All information should be accurate and legible- if a mistake is made then place a single line through the error and initial the error then place the corrected statement after the entry Record all communications with clients in the record and initial One record per patient SOAP- subjective, objective, assessment, and plan Subjective: animal’s overall appearance (attitude) Objective: vitals- TPR (temperature, pulse, respiration), weight Assessment: veterinary diagnosis Plan: treatment or procedure
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Filing Medical Records
Paper or computer records are available but most facilities use a combination of both Paper- stored in a file with pockets or clasps Computer- various programs exist Common filing systems Alphabetical- usually client’s last name with color code and first two to three letters of last name Numerical- client assigned number or each patient assigned number. With this system each digit is assigned a color and the year is clearly identified.
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Consent Forms and Certificates
Consent Forms are used to identify to the client any recommended procedures with prices while patient is under the veterinary facility care Client signs consent form to show agreement of medical care and risks Serves as a legal agreement Neuter certificate provides proof that pet has been spayed or castrated and is no longer sexually intact Rabies certificate: rabies is legally required and will show proof if an animal bites another person or pet Health certificate: issued if an animal is being transported out of state or out of the country- (includes a physical exam from a veterinarian that states the animal is free of disease and required vaccinations are up to date)
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Medical Records as Legal Documents
Staff should protect the personal privacy of clients by maintaining confidentiality All information in a record is private and not to be discussed without approval Client should sign a waiver of confidentiality for release of records
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Invoicing Veterinary Assistant should be able to invoice procedures
Can be completed on paper or with computer program
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