Record Categories
These extremely important forms within a medical record document the client’s consent for treatment to be performed.
What is a consent form
IV
intravenous
HBC
Hit by Car
Taken rectally
Temperature
EOD
Every other day
Medical notes recorded regarding any normal or abnormal experiences during surgery
What is Surgical and Anesthesia Reports
DOA
Dead on Arrival
BID
Give twice daily
how to check respiratory rate
count the number of breaths for 15 seconds and multiply by 4
RBC
Red Blood Cells
Detailed notes within a medical record taken by medical personnel
What is progress notes
NPO
Give nothing orally aka nothing by mouth
Give three times daily
TID
Count the number of beats for 15 seconds and multiply by 4
Heart Rate
UA
urinalysis
This section of a medical record is an outline of the patient’s history and contains very little details.
What is a Master problem list
Subcutaneous
What is SQ
Rx
Prescription
apply pressure to gums, release and count number of seconds it takes to turn from white to pink
ID
intradermal
contains important details about a client and their patient
what is Client and patient information sheet
CBC
What is a complete blood count
D/V
Dorsal/Ventral
Neurological symptoms
Eye twitching, pain reflex, flipping rear paws
CPR
Cardiopulmonary resuscitation