Daily Medical-Record Preparation Tasks
Pull charts for tomorrow’s clients or schedule add-ins.
Upon the client’s arrival, mark the patient’s medical record with the date and a brief synopsis of the reasons for the visit.
Check for and enter phone, address, and email updates in clients’ records.
Check for and enter medical updates (spay/neuter status, immunization status, microchip number) in patients’ medical records.
For patients that are being admitted, attach cage label and completed client-consent or other forms to the medical record.
Medical-Record Filing Tasks
Understand the medical-record filing system.
Know all possible locations for storage of records of hospitalized patients.
Properly use bins or slots assigned to doctors, staff, pharmacy, lab, and callbacks.
Accurately file all paper medical records.
Scan all written medical records when requested.
Check for misfiled records and file them properly.
Understand the definition of an “inactive” client or patient record. Every 36 months, remove or “purge” records of patients who meet the inactive status. Store these records digitally as directed.
Retain a list of inactive clients, and know where inactive files are stored.
General Medical-Record Tasks
Ensure that medical charts or records to be filed are complete and that they include current laboratory test results, doctors’ notes, and forms. Ensure that records have been updated to reflect financial transactions, medications and products dispensed, weights, immunizations, and diagnoses.
Understand and properly use special record notations, including male, female, aggressive, caution, no credit/charging, and inactive.
Transfer patient records upon written request of clients and approval of attending doctors or the practice owner.
Learn, understand and use the clinic’s approved abbreviation list.
Update — June 26, 2024
- When pet-insurance records are requested, send SOAP notes (paper chart) to the insurance company.
- Do not write anything in the chart that should not be seen by the client or outside parties.
- Have another person review the chart before sending to confirm that no inappropriate non-medical notes are included.
- Document where the records were sent, how they were sent, and the date and time sent.
- Have both reviewers initial the chart entry.
- Add a quick Avimark note so staff can verify the records were sent without pulling the paper chart. Use the line item called "Medical Records - Sent"
Source: 2016 manual.
- Merged pet-insurance/SOAP-note handling update from June 26, 2024 reminders.