Verification and Completion Requirements

Under VetView's Medical Records Management system, two things may be required for a Medical Record Group to be considered "sufficient":

• If the Medical Record Group category is Required for the episode type, a document must be present
• If the Medical Record Group requires Verification, or the Document added to the Medical Record Group requires Verification, then the document must also be verified

This setup occurs at the Episode Type setup level for the entire hospital.  

How do I mark a document as Completed on a patient record?

Documents, Requests, and SOAPs on the Medical Record will show as Required with nothing in the category when it was set to Required status based on the episode type but not completed.

First you must add the missing document, request, or SOAP.

How do I verify a document or SOAP on a patient record?

Once the missing portion of the medical record category has been added, you will then have the option to Approve.  Approval of SOAPs, TPRs, and Diagnosis is based on a privilege.  Users who have the privilege will get the option to click on the Verify button to signal that it has been added and completed.

By right clicking the header of the category, you will get the option to Approve All.

Documents that have been added but not yet verified will display a red X next to the document name.

Clicking on the X or right clicking and choosing Verify from the menu on the header will open the Document Verification Window.

This window allows you to do a mass verification of all documents for which you have approval rights.

The person who will verify can be someone other than the logged in user, allowing for an "over the shoulder" verification on a student's laptop by a supervising clinician, after reviewing the documents on this screen.  This means that the clinician in charge of verification does not have to find their own laptop, log in, and perform the verification.  This should greatly speed up the review and approval process in preparation for discharging the episode.

After it has been verified, the red X next to the document name will change to a green check mark.

For this episode, the missing required SOAPs have been added and verified, and the missing verification on the Default Physical document has been added.

These documents are considered Completed in the medical record, and it will no longer be considered Deficient after the patient has been discharged.

Why can't I check certain documents and requests?

Each Document and Request has assigned roles that are allowed to verify them.  This prevents students and staff from verifying documents when they do not have authorization.

If there is a document that you believe you should have the rights to verify, contact your unit manager or whoever assigns privileges to verify that your roles are correctly assigned. 

How do I verify the MAR record group?

On the MAR, click on the red MAR Incomplete button to start the process.

Unlike the Documents and Requests, the MAR record group will open its own window.

Ensure that the Qty totals for the administered medication match the dispensed totals, and that the dispensed lines are appropriately filled out (e.g. for Wasted methods, there must be a witness.)

Then enter in your password to approve the MAR.  The user must have the privileges to Edit MAR to be able to make any changes and approve a MAR on this screen.