Hospital Medical Record FAQs

What is a Catalog?

A Catalog is a list of all the available Documents and Requests that a particular unit might typically add to a patient visit over the course of the episode.

A unit may have multiple catalogs to help keep the documents organized by their medical record groups.

A Catalog Item is a container that holds a digital document, any charges, any lab tests, any reminders, and any other information that should be bundled together with the digital document.

For example, a catalog item for a vaccine could include the formal vaccine form, the product charge for the vaccine, the charge for the service of administering the vaccine, and a patient reminder to come back for a booster in a set period of time. 

What is the difference between a Document and a Request?

A Document is a form that is intended to be filled out by the service unit that is attending to the patient.  

A Request is intended to be filled out and handled by a different service area in the hospital.

For example, if you are the Small Animal Surgery unit, your surgery forms will be Documents that you and your students are responsible for completing.

But the Anesthesia form is a Request to be sent to that different service area, and you will answer a few questions but ultimately the Anesthesia department will be responsible for filling out the form, verifying the request, and marking it as completed. 

What is the difference between a Catalog item and a Product?

A Product in VetView is a service, inventory item, or fee that is added to the patient's bill.  A Catalog item is the documentation for the actual service being performed, and can contain the charge for the service, any inventory items, or fees.  

Catalog items can add product charges automatically, or products can be added separately as line items on a bill, if they were used on the patient outside of the scope of the services and charges included with a catalog item.

Catalog items cannot be added directly to the bill, since they usually include a form that must be filled out on the patient record.  Only products can be added there.

What is a Digital Document?

A Digital Document is an electronic form that can be attached to catalog items for hospital staff to complete when reporting on the clinical care that was provided for a patient in the facility.  Each digital document is built from custom document elements which can be any number of questions, information, or macros that make up the components of a fillable form.  

These documents can be printed or forwarded electronically to parties outside the hospital once they have been completed a verified.

Digital documents can be used alongside SOAPs as a teaching tool to help your students document the progress of a patient through each visit. 

An example of a Digital Document that will appear in the Discharge section of the patient record:

What is a document element?

A Document Element is an item on a digital document or request question.  

Document Elements can be any number of fields, including custom-made questions with a wide range of answer types (check boxes, value lists, text boxes, etc.), text called "report info" which are pulled from other portions of the record, specialized fields such as "patient ID" which feed into other portions of the patient's record (such as microchip numbers or rabies tag numbers).  

Each element type can have macros associated with them and/or can have related questions associated with them as well.

An example of a Rabies Tag element:

What is a Medical Record Category?

The Patient Record contains virtual folders called Medical Record Categories.  These can be expanded and collapsed to view their contents.

Each medical record category can have its own requirements set by your hospital administration:  A category may be required on a specific type of episode, and certain categories may need to have their contents verified by a clinician as well.

Every episode has, at a minimum, the Personnel and Billing sections.

All other sections will appear based on the episode requirements, or as new Documents and Requests are added.

Where can I find the result of my requests?

The Status of each request will appear on the header of the request in the patient record.

The Results of the request will appear below if you expand the request.  For lab requests in Working status, actual results may be blocked until the accession is finalized on the Labs side.

How do I add a SOAP to a patient record?

To initiate the SOAP process, you first must add a problem.

Right click the episode header, and choose Add Problem.

Add the problem you intend to SOAP (or have your student SOAP) and click on Save.

You can SOAP the entire patient, or SOAP individual problems.  You can also mix and match as needed: in the example below, Subjective and Objective were applied to the visit, but the Analysis has been added to the specific Problem.

My Request Screen is loading blank! How do I see my Requests?

In order for a user to see Requests, they must be assigned to at least one Request Unit under Hospital Setup. This is separate from all the other user role privileges they may be assigned.

If you cannot see any units under the Request screen, contact your supervisor or unit administrator to be added as a member of the Unit.