Medical Record Tracking
- Cathy Allison
Medical Record Tracking
The Medical Record Tracking screen is an optional system in VetView designed to support physical copies of your patient's medical records. While the ideal in a modern hospital environment is to go fully "paperless" there are still many reasons to have physical records, such as redundancy and offline support, storage concerns for digital archives, and the need for certain types of paper documents that cannot be recreated in VetView at this time (notably image based body condition scores.)
When used in conjunction with the Medical Record Management screen, you can create a precise 1:1 copy of the patient's digital record in a physical format, and use this Tracking screen to identify the last known location of a physical volume of the medical record.
Single Record Tracking
When this screen first loads, everything will appear empty. Physical records are created and tracked based on the digital record, so you must start by entering a case number.
After entering a case number, click on the Find Case button. Log entries for the patient's volumes will then appear.
| Field | Description |
|---|---|
| Selected Case Details | The patient index card and owner index card of the case number that was entered. Mouse over the info dot on the patient to see additional information. |
| Volume Name | The name of the medical record volume you are currently working with. The default name for the first volume of a patient will be Primary. As additional volumes are added, this can be changed. |
| Edit Name | Click on the pencil icon to edit the name of the current volume. Depending on whether your volumes are named by service area, year, or sequentially until they are full, you can name this whatever is appropriate based on your hospital's policies. |
| Status | Select the radio button to indicate that this volume is being checked out (by clinical staff for a case) or back in (returned to shelves.) |
| Date | The date this volume changed status. Can be backfilled if the clinical team returned it earlier in the week and it is only now being processed. |
| Reason | For check outs, the reason the volume is being taken out of the records department. These can be customized under Hospital Setup > Medical Record Setup > Medical Record Transfer Reasons. Custom entries allow you to track the exact service areas and reasons that clinical staff have removed a volume, which may assist in identifying its last known place in the logs if it goes missing. |
| Staff 1-2 | The staff member being entrusted with the volume, or the ones returning it. If the staff member is a student, then their supervisor can be included as well. |
| Unit | The unit who is checking this record out or returning it. |
| Comments | Any additional comments regarding this volume being checked out or checked in. Use this to explain discrepancies in the log - for example, it was checked out by one student for the Internal Medicine unit, but the patient had a same day appointment with Oncology, and the patient alongside the volume were transferred there. Oncology then was the one who returned the record. |
| Save | Applies the changes and adds and entry to the log. |
| Copy | Copies the current information. May be useful for a batch of new records being created. |
| Paste | Pastes the last copied information. |
Add Another Volume
Click on this button to make an additional physical volume of the patient's medical record. Use this feature if you have run out of space in the first volume, or if your hospital utilizes separate volumes for different service areas or years.
Click on the Save button, and a new field set for the new volume will appear.]
Log Entries
Log Entries show a record of information as the clinical team checked out and returned the record. For each Out, there should be a matching In. If this is not the case, it means that the volume was not properly checked in after it was returned to medical records at some point, or another issue occurred. Use the logs and comments to identify any potential workflow issues in your hospital for tracking the physical records.
Multi Record Tracking
This tab allows you to perform an action on any existing medical record volumes in a batch.
In the example below, older patients are having their records digitally scanned to be archived off site to free up space in the records department. They are are being checked out in bulk, and once the scan is complete, may be destroyed or recycled.
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.