T/F: Never write in pencil when recording in a veterinary medical record. - ANSWER True
T/F: the veterinary-client-patient relationship or VCPR must be maintained legally within 2
years. - ANSWER False, it must be maintained within 1 year.
T/F: the health certificate must include vaccine dates of an animal. - ANSWER True
T/F: the veterinary assistant must record an animal's history, but it is not necessary to note
any communications with the client by phone or verbally within the medical record. -
ANSWER False, all client communications should be recorded.
What vaccine is legally required to be given to some animal species? - ANSWER Rabies
How many years are states required to keep medical records? - ANSWER 3 years
Which filing method is most commonly used in veterinary facilities? - ANSWER
Alphabetical
Where is the SOAP recording method commonly used? - ANSWER Patient progress notes
The temperature and heart rate of an animal are examples of which element of SOAP? -
ANSWER Objective
What should you do if a mistake is made when recording in a medical record? - ANSWER
Place a single line through the error, correct it, and initial
1
,When is it appropriate to share information on medical records? - ANSWER Only when
information shared is for the purpose of patient care
In the SOAP format for progress notes, in which category would the chief complaint be
written? - ANSWER Subjective information
Who owns the physical medical record? - ANSWER The veterinary practice
T/F: stamps and stickers should not be used on any medical records because they are legal
documents. - ANSWER False
T/F: when discharging a client and patient the veterinary assistant must check ALL of the
following: that discharge instructions are clear, that the client had all of the prescribed
medications, and that the client had made a follow up appointment if necessary. -
ANSWER True
Place once single line through any error made in the medical record and then correct and
____ the mistakes. - ANSWER Initial
Each letter of the alphabet label is assigned an individual ___. - ANSWER Color
Progress notes are recorded in ___ order in the medical record. - ANSWER Chronological
The ____ ____ ____ details a patient's past surgeries, medical conditions, and vaccines. -
ANSWER Master problem list
The ____ ____ is the reason the veterinarian is seeing the patient during an appointment. -
ANSWER Chief complaint
2
,Objective information - ANSWER Measured facts based on an animal
Patient - ANSWER The animal seen by the facility
Medical record - ANSWER Detailed information written about each animal
Consent form - ANSWER Identifies procedures to the owner and allows the owner to
authorize them
Assessment - ANSWER Vet's diagnosis of an animal's problem
Neuter certificate - ANSWER Proof of a spay or castrations surgery
Plan - ANSWER Treatment or procedure given to an animal
Progress notes - ANSWER Log entries made of each treatment
Subjective information - ANSWER Opinion of animal's appearance and attitude
Health certificate - ANSWER Form to allow an animal to travel
T/F: it is helpful to cross off or place an X in the appointment slot when no office
appointments should be scheduled. - ANSWER True
T/F: it may be helpful to color code a multiple doctor appointment schedule. - ANSWER
True
3
, There is not any type of appointment that must be approved by the veterinarian. -
ANSWER False, _____ need to be approved by the veterinarian.
T/F: walk-in clients are encouraged by veterinary facilities. - ANSWER False, walk-in
clients can disrupt the normal schedule.
T/F: each staff member must know the veterinarian's abilities and time frames to schedule
procedures. - ANSWER True
T/F: the client should suggest a preferred date and time for the appointment. - ANSWER
True
T/F: it is only necessary to call and remind clients of appointments if they did not receive an
appointment card. - ANSWER False, appointment cards can be forgotten or misplaced,
and it is common courtesy to give a reminder call.
T/F: the appointment schedule should be completed in blue or black ink. - ANSWER False,
many appointment schedules are computerized.
Which of the following is NOT a pre-surgical instruction for a surgery patient?
A) Do not feed animal 12 hours before surgery
B) Do not give water 8 hours before surgery
C) Restrict activity 8 hours before surgery
D) Arrive with the pet at a specified drop-off time - ANSWER C. Restricting activity in an
animal is very difficult and is not necessary before surgery.
What is the most common appointment schedule type? - ANSWER Flow schedule
What is the most common appointment interval time? - ANSWER 15 minutes
4
T/F: the veterinary-client-patient relationship or VCPR must be maintained legally within 2
years. - ANSWER False, it must be maintained within 1 year.
T/F: the health certificate must include vaccine dates of an animal. - ANSWER True
T/F: the veterinary assistant must record an animal's history, but it is not necessary to note
any communications with the client by phone or verbally within the medical record. -
ANSWER False, all client communications should be recorded.
What vaccine is legally required to be given to some animal species? - ANSWER Rabies
How many years are states required to keep medical records? - ANSWER 3 years
Which filing method is most commonly used in veterinary facilities? - ANSWER
Alphabetical
Where is the SOAP recording method commonly used? - ANSWER Patient progress notes
The temperature and heart rate of an animal are examples of which element of SOAP? -
ANSWER Objective
What should you do if a mistake is made when recording in a medical record? - ANSWER
Place a single line through the error, correct it, and initial
1
,When is it appropriate to share information on medical records? - ANSWER Only when
information shared is for the purpose of patient care
In the SOAP format for progress notes, in which category would the chief complaint be
written? - ANSWER Subjective information
Who owns the physical medical record? - ANSWER The veterinary practice
T/F: stamps and stickers should not be used on any medical records because they are legal
documents. - ANSWER False
T/F: when discharging a client and patient the veterinary assistant must check ALL of the
following: that discharge instructions are clear, that the client had all of the prescribed
medications, and that the client had made a follow up appointment if necessary. -
ANSWER True
Place once single line through any error made in the medical record and then correct and
____ the mistakes. - ANSWER Initial
Each letter of the alphabet label is assigned an individual ___. - ANSWER Color
Progress notes are recorded in ___ order in the medical record. - ANSWER Chronological
The ____ ____ ____ details a patient's past surgeries, medical conditions, and vaccines. -
ANSWER Master problem list
The ____ ____ is the reason the veterinarian is seeing the patient during an appointment. -
ANSWER Chief complaint
2
,Objective information - ANSWER Measured facts based on an animal
Patient - ANSWER The animal seen by the facility
Medical record - ANSWER Detailed information written about each animal
Consent form - ANSWER Identifies procedures to the owner and allows the owner to
authorize them
Assessment - ANSWER Vet's diagnosis of an animal's problem
Neuter certificate - ANSWER Proof of a spay or castrations surgery
Plan - ANSWER Treatment or procedure given to an animal
Progress notes - ANSWER Log entries made of each treatment
Subjective information - ANSWER Opinion of animal's appearance and attitude
Health certificate - ANSWER Form to allow an animal to travel
T/F: it is helpful to cross off or place an X in the appointment slot when no office
appointments should be scheduled. - ANSWER True
T/F: it may be helpful to color code a multiple doctor appointment schedule. - ANSWER
True
3
, There is not any type of appointment that must be approved by the veterinarian. -
ANSWER False, _____ need to be approved by the veterinarian.
T/F: walk-in clients are encouraged by veterinary facilities. - ANSWER False, walk-in
clients can disrupt the normal schedule.
T/F: each staff member must know the veterinarian's abilities and time frames to schedule
procedures. - ANSWER True
T/F: the client should suggest a preferred date and time for the appointment. - ANSWER
True
T/F: it is only necessary to call and remind clients of appointments if they did not receive an
appointment card. - ANSWER False, appointment cards can be forgotten or misplaced,
and it is common courtesy to give a reminder call.
T/F: the appointment schedule should be completed in blue or black ink. - ANSWER False,
many appointment schedules are computerized.
Which of the following is NOT a pre-surgical instruction for a surgery patient?
A) Do not feed animal 12 hours before surgery
B) Do not give water 8 hours before surgery
C) Restrict activity 8 hours before surgery
D) Arrive with the pet at a specified drop-off time - ANSWER C. Restricting activity in an
animal is very difficult and is not necessary before surgery.
What is the most common appointment schedule type? - ANSWER Flow schedule
What is the most common appointment interval time? - ANSWER 15 minutes
4
