1
the key to successful history taking
Communication
Listening to sounds produced by the body is termed
auscultation
A slower-than-normal heart rate
bradycardia
MOST important and is obtained from the client, Includes reason for the visit (primary complaint), patient history, and observations made by the client
Subjective
Cannot be used to fix mistakes on paper records
White-Out or correction fluid
main reason why the client has sought veterinary care for the animal
The presenting complaint
allows auscultation of specific areas within a body cavity for assessment of the cardiovascular, respiratory, and gastrointestinal systems
The stethoscope
A faster-than-normal rate is
tachycardia.
information is gathered directly from the patient, FACTUAL
Objective
includes any conclusions reached by the veterinarian from the subjective and objective findings, Also includes the definitive diagnosis
Assessment
Surgery patients should be physically examined within ______hours of having anesthesia.
12
may occur with infection, sepsis, toxicity, inflammation, brain lesions or tumors (loss of thermoregulation), heat stroke, seizures, stress, and excitation.
Hyperthermia
is the rate of return of color to oral mucous membranes after the application of gentle digital pressure and is indicative of the perfusion of the peripheral tissues with blood.
capillary refill time (CRT)
Legal documents; property of the practice, Inactive records must be maintained for 3 years
Medical Records
is developed by the veterinarian based on the assessment, This will include any treatment, surgery, medication, intended diagnostics or intended communication with the client
Plan
k9: HR, PR, Temp
70-160 8-20 (99.5°-102.2° F)
can occur with shock, severe sepsis, severe cardiac insufficiency, multiple organ failure, poor perfusion secondary to anesthesia or surgery, or low environmental temperatures
Hypothermia
are the two most common modalities available in the clinical setting
Radiography and ultrasonography
must be initialed
Mistakes
Most common error (when documenting) is...
not documenting communication with the owner regarding the prognosis of the patient
Feline Vital Signs
150-210 8-30 (100.4°-102.2° F)
indicates that tissues in the area tested have reduced blood perfusion.
A prolonged CRT (>2 seconds)
a form of electromagnetic radiation.
X-rays
MUST be in permanent ink
Entries in written records
Medical record belongs to...
Practice