Maintenance of Medical Records

The following protocol describes how County Seat Animal Hospital's medical records are maintained so that they contain complete and accurate information in a secure and confidential system.

PURPOSE

Accurate, complete, and accessible medical records are essential to quality medical care. Ethics and legal responsibilities require that medical information be kept confidential.

 

PERSONNEL

Medical records may be handled and reviewed by the doctors, veterinary technicians, and
business office members of County Seat Animal Hospital. Upon the approval of a clinician or veterinary
technician, individual medical records maybe viewed by all other employees. Any employee not engaged
in medical care of a patient is not allowed to make entries into the medical records.

LOCATION

All medical records are kept on the practice premises. These records are electronic and may be accessed by any computer installed with ImproMed Infinity Software. A daily back up of information is stored and taken out of the building each night. The owner will take this information home with him for safe keeping in case of natural disaster and/or fire.

 

ENTRIES

Any employee may make an entry into the medical record regarding any communication with the client or anyone who wants information about the paitent.

Veterinarians only may make entries into the medical record regarding the patient status and care throughout the visit. Veterinarians can dictate the medical record at any time to a County Seat

Animal Hospital employee. The employee must log the information as being inputted by the veterinarian and then note their own initials at the bottom of the entry.

CONFIDENTIALITY

Any County Seat Animal Hospital employee may divulge the vaccine history of a patient over the phone or via fax. Each employee must make a note of when and to whom this information was given. All medical records can only be released at the request of the client. All veterinarians must be informed whenever a medical record is being transferred from County Seat Animal Hospital. All employees must make a note in the medical record of when and to whom the medical record was released.

RECORD MAINTENANCE

VetFMSoftware will house all saved files in the medical record. Any open or
unfinished medical record entries will be listed in the "needs charges" section of the VetFM
Software Census page for the veterinarian to complete his or her entries. The office manager is ultimately
responsible for 100% completed medical records for every patient.

SUPERVISION

The office manager of County Seat Animal Hospital will oversee the maintenance of all electronic and physical medical records.

Medical Record Information

The County Seat Animal Hospital utilizes a written protocol for how medical record information is provided to the client.

Who approves the communication of the medical record

The form in which the communication is delivered such as fax, telephone, email, or photocopy

Under what circumstances and in what form the medical record or supporting documents such as radiographs, diagnostic results, or veterinarian's entries can be delivered to the client.

 

The County Seat Animal Hospital recognizes that clients often have a need for the information contained in
their pet's medical records. The goal of this protocol is to ensure that the clients have timely and ready
access to whatever information they need regarding their pet's medical records. Additionally, all members
of the County Seat Animal Hospital recognize the confidentiality of medical records and their

responsibility to protect that confidentiality. By adhering to the following principles and guidelines, we will be able to consistently and effectively meet our clients' needs.

The basic principle the practice follows is that the provision of medical information is the responsibility of County Seat Animal Hospital. As such, any request for medical record information will be taken seriously and addressed promptly. Any request for medical records, whether in person or by phone, fax, email, or mail will be accepted. The final responsibility for oversight of the medical records will reside with the office manager and owner.

Due to the potentially sensitive nature of medical records, they re to be reviewed by a veterinarian prior to being released. The exception to this is that any member of the practice team may release information about whether or not the pet was/is a patient of the County Seat Animal Hospital, and the date of the last vaccination given. Medical records will be released only when authorized by the client or an appropriately

 

designated representative of the client. An appropriate representative is considered to be anyone the client specifically authorizes, anyone who is routinely involved in the communication about the patient, and any veterinarian who is currently treating the patient. Also, records may be released as required by law.

Once the medical record has been reviewed, the information will be delivered as soon as possible and in an appropriate manner. This may take the form of a veterinarian summarizing the record over the phone in cases where immediate communication is needed. In other cases, this may be faxing, emailing, or mailing a copy of the records. The client can also request copies of any diagnostic testing (blood work, radiographs, ultrasound, etc.). There are no fees for these services and all services will be performed within an hour of the request.

Discharge of Hospitalized Patients

County Seat Animal Hospital utilizes a written protocol for the discharge of hospitalized patients.

No patient is to be discharged unless their chart has been completed and moved to the "Ready to Check Out" section of the VetFM Software census page.  All check out instructions must be followed before the employee can begin the discharge process.

Once the client has paid all fees for the patient, the employee must check with either the office manager or veterinarian to make sure they can begin the discharge process. Upon approval the employee is expected to:

-Make sure the patient is: alert, clean, in a little pain as possible, groomed, and deodorized before delivery to the owner.

-The employee must also check the patient's cage and surrounding area for collars,
leashes, beds, food, supplies, or any other personal belongings.

All patients must be approved for discharge by the veterinarian or office manager before they are allowed to be released from the hospital. There is no excuse for a patient and client to leave without receiving their discharge instructions and having time to ask questions about their pet's procedure. All client communication will come from the veterinarian or office manager directly. If neither are available in person, then the employee must contact them to receive instructions for a patient's discharge.

Forms Protocol

County Seat Animal Hospital uses a variety of forms to convey information to our clients. We also use many forms to keep track of in house activity. Below is a list of forms used, who is allowed access, and the presentation of the form in a particular media.

Any form listed below may be photocopied, emailed, mailed, or faxed when necessary keeping in line with the medical records protocol.

 

Client Information

Euthanasia Release

Preheart 6

Dental

Anesthesia Monitoring

Dental Authorization

Pain Evaluation

All employees are allowed to photocopy, fax, email, print, and distribute any of the forms listed above

under the supervision of the office manager or veterinarian on staff.

All new or changes in any forms must be documented in the medical record area of our electronic records.