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Avoid these Medical Record Mistakes

  |   Practice Management
  • Illegible entries
  • Inappropriate entries
  • Failing to document recommendations and owner declinations
  • No consent forms
  • No documentation on boarded animals, especially medical boards (such as diabetics)
  • Lack of records, incomplete information
  • No anesthetic drugs, dosages, anesthetic monitoring entries
  • Incomplete charting of physical examination
  • No surgery report, no suture or sponge count information

Tips provided by AVMA-PLIT

 

Posted January 4, 2019