A N I M A L N U R S I N G P RAC T I C E

ADMISSION, DISCHARGE AND MEDICAL RECORDS

RECEPTION DUTIES INCLUDE BOOKING APPOINTMENTS

• For consults• For surgeries• For house calls

• Admission best in a separate room so client can discuss detail with admitting staff

CLINIC ADMISSION POLICY SHOULD BE CLEAR

• Who admits patients if vet not available• When the pre-op check takes place• Owner visits to see where animals will be

hospitalised

• Check contact details and up to date status of the animal and record

REMEMBER

• Record all possessions the animal is admitted with• Suitable restraint when moving animals around to

kennels/cattery• Ask owner to leave the animal rather than try to

drag the animal away from the owner• Get consent forms signed and ensure owners

understand them (18+years)• Ensure estimate of costs given and recorded and

if problems prearranged payment plan

PROTOCOLS FOR ANIMALS ADMITTED

• Identification system and inpatient records• Appropriate enclosure for species

DISCHARGE

• Before the animal is presented• Clean animal• Discuss case with

the owner• Collect the fee• Book revisit• Return belongings• Dispense meds and

explain their use

• After the animal is presented• Demonstrate any

ongoing care required • Check the owner is

confident to cope• Encourage the

owner to contact the clinic if concerned

ROLE PLAY

You are the receptionist on duty in a busy multi-vet practice, and a client is ringing to book an appointment to get their cat its annual vaccination. Ensure you gather up to date contact details and check who their usual vet is. The reason for the visit and give an estimate of the usual cost. Give clear instructions for the restraint of the cat as it is brought into the clinic

You are the nurse on duty first thing in the morning and the vet does not arrive till later. The client has brought their pup in for a spay operation later that morning. It is your job to admit the animal, its possessions, update any records required, get the surgical consents signed carry out practice policy about the owner in the kennels and get the animal settled in the hospital

MEDICAL RECORDS

MEDICAL RECORDS

• individualised record of all the medical interactions and information the clinic has on an animal

They provide• continuity of care• Reference of past medical history relevant to

current problems• Information for financial management• Legal evidence in court

MEDICAL RECORD IS COMPOSED OF…

• Client and animal details• Hx• PE• Dx • Prognosis• Authorisations• Lab and radiography reports• Sx and anaesthesia records• Tx and hospital records

• May or may not include financial records

WHO OWNS THE MEDICAL RECORD?

• A client is moving to another town and asks for his medical record so he can take it to the next vet. The vet is on a lunch break, is he legally entitled to the file?

• What do you do?

PURGING OLD FILES

• 3 years after the last visit clients can be filed as inactive

• Old records can be destroyed after 7years

• Shred or burn

COMPUTERISED RECORDS

• Most practices use database software the staff must be able to use

HANDWRITTEN MATERIAL

• Legible• Indelible• Accurate• Corrections dated and signed original still legible

THE MEDICAL RECORD IS CONFIDENTIAL

• May not discuss medical records with outside party without clients written permission

• Except if court requests