Medical Record Management Page
- Cathy Allison
Medical Record Management
The Medical Records Management screen is a single point to monitor, review, and correct medical records within VetView. Patient records during a visit should be filled in and maintained by the clinical team, adding the appropriate documents and requests, and then reviewing and verifying them. For patient visits with senior students, the student should fill in SOAPs and have them approved by a supervisor. Medication Administration Records should be filled in by the clinical team and then corrected or approved by the pharmacy team.
This screen also allows an automatic message to be sent to the clinical staff who were intended to complete a medical record, letting them know what is missing. Deficiencies for records are visible on the episode and on the Patient List at all times.
This screen also provides an all in one place to print a hard copy of a patient visit, including all the documentation. Individual components can be printed to fill in the gaps from what clinical staff have already printed out.
Medical Records Management Search
The top section of the Medical Records Management screen is a search box. Use this to find the medical records you want to review, correct, or close.
All search criteria can be combined together to get a specific batch of episodes. For example, select the unit, and the Discharge date range, and the deficient flag, to find all deficient episodes for that unit that were discharged after the specified date.
| Field | Description |
|---|---|
| Episode | Search for a specific episode using the PA# / episode number. This should pull up exactly one result. |
| Animal ID | Search for the medical record for a specific patient by name. This will list all the episodes in the system for any patients which match the other selected criteria. |
| Nickname | Search for the medical record for a specific patient by their nickname. |
| Case No | Search for the medical record for a specific patient by case number. This will list all the episodes in the system for one patient. |
| Client | Search for the medical record for a specific client by name. The Animal ID can be used in conjunction with the client's last name to greatly reduce the number of matches. |
| Unit | Search for all medical records in a specific unit. Use this in conjunction with other search criteria to identify records for your service area that need attention. |
| Personnel | Search for all medical records that have a specific user assigned to the episode. Use this in conjunction with other search criteria to identify records associated with that one user that need attention. |
| Search Options: Date Types | Choice between the date the episode was created and set to New status, the date the episode was Opened, the date the episode was Admitted, the date of Discharge, the date it was Closed, and the date it was set as a Consult (where applicable.) |
| Date Range | The range of dates. Use in conjunction with the Date Types to search for episode statuses within that date range. To search for all episodes after a specific date, use that date as the start date, and leave the end date blank. |
| Current Status | Searches for episodes using the current episode status, regardless of what status date is chosen. Using this, you can search for episodes created two months ago that are still open, to identify which episodes need to be manually discharged and closed. |
| Other Options | Choice between Deficient, Admitted, and Deceased. Use these flags to identify other types of records which may need additional attention. For example, Deceased + Discharged patient episodes should be reviewed and closed, regardless of whether they are deficient or not. |
Search Results
After selecting the search criteria that matches what task you are attempting to accomplish, click on the Search button. Episodes that match will appear in the list below. These columns cannot be sorted - if you have too many results to work with, narrow your search criteria.
Click on the View icon (binoculars) to open the Medical Record Details screen and work with that one specific episode.
Use CTRL+Click on the Episode or Patient name to open the medical record in another tab.
Notify Clinicians
To send a batch notification regarding deficient episodes, select the episodes using the check box, and then click on the Notify Clinicians button. A window will open to allow you to send a message.
This message will automatically include the patient name, case number, and episode link for each of the selected episodes. You can customize the message before the list with additional instructions and apply basic formatting to the text.
Discharge DVM is always included, as they are usually considered the person responsible for saying the episode was completed enough to let a patient leave, but you can also notify any other personnel on the episode who may be responsible for the work, such as the attending DVM or all the students listed on the episode.
Medical Record Details Screen
The Medical Record Details screen gives you an overview of the status of each of the groups on the medical record, as well as actions to perform on the sections and the option to send a note to the clinical staff about the issues.
Use CTRL+Click on any of the underlined fields to open them in another tab of your browser.
| Field | Description |
|---|---|
| Back to Search | Returns to the main Medical Record Management screen, but preserves the search used. Use this instead of the browser's back button to avoid having to re-enter everything. |
| View Episode Bill | Opens the bill associated with this episode on the Order Management Screen. Use CTRL+Click to open it in a new tab. Compare the charges on the bill to the documents on the episode to review and ensure everything was accounted for in both places. |
| Deficiency Note | Opens the Deficiency window to allow you to send a VetView internal mail to the parties responsible for updating a deficiency episode. |
| Episode Information | High level information about the episode, such as the status, date it was opened, and the episode type that was used to generate the deficiency check. |
| Print Selected Components | Prints the report associated with that section of the medical record. To print the entire Episode of Care, click on the square at the top of the column to select everything, then click Print Selected Components. The PDF reports will be joined together as a single unified PDF to allow for a single print job. |
| Add Requirement | Add a new required medical record group to the episode. Use this if there is a charge for something on the patient order, but no matching report. |
| Edit Requirement | Modify the medical record group requirement. You can adjust whether the medical record group should display on the record at all, whether it is required to have a document or request inside it, and whether that document or request must be verified by a clinician. You can also add a comment explaining why the change was made. |
| Exempt | From the Add/Edit Requirement windows, you can click the Exempt button to clear the Required or Requires Verification flags without removing the medical record group, This may be useful when processing deficiencies on older records, or when there is a valid reason for the report to not be added (e.g. the system was down and the report was hand written on paper and will instead be scanned into the medical record as an attachment.) |
Add/Edit Requirement Window
When the Add Requirement or Edit Requirement buttons are pressed, a small window will open to allow you to modify the requirements.
Close Episode
When all parts of the medical record have been filled in and approved as needed, the Medical Records Staff can close the episode from the Medical Records Management screen without necessarily opening the patient record. You can have your hospital settings such that an episode must have all flags cleared before it is closed.
The page will reload, and the episode status will change to closed.
VetView Wiki Most recent releases of VetView: Version 4.2.5 Hotfix (Released 10/31/2024)
To see commonly used terms in VetView Hospital, please visit our Hospital Glossary of Terms.