Читать книгу Textbook for the Veterinary Assistant - Lori Renda-Francis - Страница 80

Every animal that is seen at the veterinary hospital should have its own medical record. The record should be dated each time an entry is made; the presenting problems should be listed, and the author must initial this entry. Veterinary hospitals vary – they may use paper medical records, be paperless, or paper light. Paper medical records must be kept on 8½ × 11 in. sheets of paper. It is important to note that index cards are no longer acceptable as the medical record. Every client interaction, every client conversation, consent form, laboratory report, consultation, physical examination, and medication administered and dispensed must be documented in the medical record. If it is not in the patient’s medical record, then “it never happened.” Many veterinary hospitals have moved to paperless medical records. Paperless hospitals have the benefit of being able to access client records, laboratory results, and radiographs at any computer station.