complete detailed solutions.
Small Animal Medicine Exam 1 with 102
complete detailed solutions.
NK cells (natural killer cells) and interferon - ANSWER NONSPECIFIC response to viral infection
Attacks foreign cells, normal cells infected with viruses and cancer cells; they are responsible for
immunological surveillance because they "police" peripheral tissues.
Primary - ANSWER Records that
•Support excellent medical care
•Documents procedures and communication
Secondary - ANSWER Medical records that
•Support business activities
•Support legal activities
Supports research
source oriented (SOVMR) - ANSWER Non-recommended medical record style that-
•Records usually kept on cards
•**Patient info kept together by subject matter**
•Information from various sources entered in chronological order by hospital stay
•Used when you have limited space
•Quick and easy
Lacks detailed documentation
_ gets disorganized in large clinics or in cases of patients seen over a long period of time with chronic
health issues.
,Small Animal Medicine Exam 1 with 102
complete detailed solutions.
problem oriented (POVMR) - ANSWER Preferred-
•Folder-type medical records
•Supports logical, organized approach
•Goes through complicated medical cases one at a time
•Information is grouped by problem, and each problem is assigned a number and addressed separately
•Notes are written on progress forms in SOAP format
•Excellent communication and team-oriented medical care with ongoing assessment and revision of
health care plan
SOAP format - ANSWER - Format used to organize data entries in the progress notes of the POVMR.
- Preferred methodfor case notes and required by clinics that wish to be accredited by AAHA
(Subjective, Objective, Assessment, Plan)
master problem list - ANSWER •Defining part of POVMR
All the problems the patient has experienced over its lifetime (All the patients history)
The first page of a veterinary medical chart, which serves as an index or table of contents for the rest of
the record
•Defining part of POVMR
•Index to patient's medical history.
•Numbered list - Some disorders will be resolved, some will be active
, Small Animal Medicine Exam 1 with 102
complete detailed solutions.
POVMR (Problem Oriented Veterinary Medical Record) - ANSWER -More organized record keeping style.
-Helps with a team approach to patient care
- preferred method
subjective - ANSWER - Patient signalment, history and client info.
patient history - ANSWER •Presenting Complaint and circumstances
•Last time the animal was "normal"
•Frequency of episodes
•Current medications (& OTC)
•Previous treatment for this complaint
•Owner concerns and comments
•Current diet
Information from referring or previous veterinarian
objective - ANSWER Results from physical exam, lab results and Dx testing.
- No interpretation; just actual, measurable data.
assessment - ANSWER - Interpretations of exams and test results that is used to generate the working
problem list.