Basic Medical Record Entries

eVetPractice offers many different ways to enter medical record notes for patients. There is no one right way, but this article gives an example on how to use each feature.

NAVIGATING TO THE MEDICAL RECORD

There are many ways to access the medical record, but the two most common ways are through the quick search feature and directly through an appointment:

Quick Search

  • In the upper right corner of the screen type in either the patient's name, client's first and/or last name, and phone number. The patient's name will generate a list of all patients with that name and the owner will be listed to the right of the patient’s name. If the client's first or last name or phone number is entered the list will generate the client name followed by a list of all the clients pets.mceclip0.png
  • Click on the patient's name to go to the medical record.

Appointment

  • If you have an appointment for a patient, left click on the appointmentmceclip1.png
  • Click "Go to MR" to navigate to the patient's medical record. *Please note the appointment must have an assigned to a patient to access the medical record from the appointment
  • Once in the medical record navigate to the patient highlights at the top of the screen:mceclip2.png

Scroll down to the beginning of the chronological medical record. Please note there are 3 different medical record views - View by Date (most common view used), View by Groups, and View by Date with Details. You can experiment with different views, but this article will focus on the View by Date view:

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  1. REASON FOR VISIT

It is recommended to have a reason for visit for each patient appointment. There are 3 ways a reason for visit can be entered into the medical record:

  1. When a patient is checked in (recommended)

When a client arrives, by utilizing Visit Status’ and selecting the status from the appointment it has the ability to copy the description of the appointment in the medical record as the reason for visit.

CHECKING IN A CLIENT FROM THE CALENDAR:

  • Left click on the appointment you wish to check in
  • Click on “Status”

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  • Select the visit status to consider to “Check In” the patient. Then Save
  1. Reason for visit can be added manually within the medical record

From the “View by Groups”, “View by Date”, or “View by date with Details” tab the staff can manually enter a reason for visit that will reflect within the medical record, on history forms, exam forms, and treatments.

From “view by groups”

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From “view by date” or “view by date with details” a Reason for Visit can be accessed from the Medical Record Quick Links box.

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  1. HISTORY FORM

Prior to the veterinarian preforming a physical exam on the patient, an assistant and/or technician discusses a history with the client on the patient. The assistant and/or technician can utilize a history form to collect and obtain the information. History forms are presented as a question and answer format with multiple answer options, free hand entry, and a dropdown list.

Choosing a History Form can be added from the “View by Groups” or “View by date” or “View by date with details”. A dropdown list will appear with the available history forms for the staff to choose from, then click Add. *Please note if you "Save and Add History" is selected from adding the Reason for Visit section above, it will also take you to this screen.

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Click "Add" and the form will appear:

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  1. EXAM FORM

Some practices choose to utilize a separate history form and exam form, while other practices prefer to create one form as an exam form that will provide the assistant and/or technician with a history section. This will also be helpful if the veterinarian is responsible for Exam form work just like history forms. The exam forms can be added through “View by Groups” and the Medical Record Quick Links box from “View by Date” or “View by date w/ Details”. Click “add Exam Form” or the Exam Form link then select the exam form from the dropdown and "Add. Here is a sample exam:

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Click Save when complete.

  1. DIAGNOSIS/ASSESSMENT

Once the exam form is completed the staff can add the patient diagnosis/assessment. The Diagnosis section allows the staff to search through pre-loaded diagnosis codes or free hand type their own diagnosis. A diagnosis can be added from the “view by groups”, medical record quick links box under “view by date” or “view by date w/ details, or by selecting “save and add diagnosis” from the exam form.

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In the "Create Master Problem" check box highlighted above, a diagnosis can be entered as a master problem if it needs to be monitored because of a chronic or severe condition.

  1. TREATMENT

Treatments in eVetPractice are also considered an invoice. From the “View by groups” tab in the medical record click on Treatments to expand the section and then click “Add Treatment”. From the View by date” tab and/or “View by date w/ details” tab click on the Treatment link from the Medical Record Quick Links Box. The screen below will appear and the staff will enter the treatments.  

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Once a billable item is added, click on the hyperlinked item to change the following options with in the Item Details. *Please note that the Rx Details will only show up if the inventory item is marked as "Is Dispensable."

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  1. DOCUMENT

Documents in the format of a photo, short video or pdf can be added to the patient medical record by uploading them from “View by groups” and Document. Documents are also able to be added from “View by date” and/or “View by date w/ details” and clicking on Document. To upload a document first give the document a name or use the file name the document is saved as on the device. Secondly, click in the white field where it says “Drop files here to upload OR click to browse for a file(s)” then save and the documents will be available within the patient medical record.

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  1. PLAN

The plan section is optional and will allow the practice staff to enter additional notes into the EMR. Typically, this section is not necessary if the plan has been included within the Exam Form.

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  1. MEDICAL RECORD NOTES

Medical record notes can be added as quick notes, procedure notes, tech apt notes etc. The form is identical to the Plan section described above.

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  1. CLIENT COMMUNICATION ENTRY

To add a client communication entry directly to the medical record. For example, if a client calls and speaks to a clinic staff member about their pet having a medical issue and the staff recommend they have their pet seen by the veterinarian and the client declines. The staff can enter that correspondence in the medical record as a client communication entry form the Patient Quick Links box or Medical Record Quick Links Box. Communication entries can also be added to the whiteboard.

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  1. To create a whiteboard entry select the option.
  2. Select an employee if needed to assign it to a specific employee on the whiteboard entry. It is not required to assign an employee. Leave on “Not Assigned” if there is no specific employee to assign to.
  3. Enter the communication type, communication method and information regarding the client communication.
  4. Then Save.
  5. ADD HISTORICAL LAB RESULTS

When a client brings in previous records from another practice containing lab results the staff will have the ability to add those results in historically. To enter the lab results from previous records (ex: heartworm tests) from the “view by groups” tab go to lab results section and click on “add historical lab results”. From the “View by date” and/or “View by date w/details” click on the link “add historical lab results”. When historical lab results are created any patient reminders will also be created in the medical record

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Once the lab have been selected, click Save, and the system will allow the staff to choose the appropriate lab form to enter the historical results.

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Once the form is chosen, the form will appear below to enter results:

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  1. ANESTHETIC MONITORING FORM

For practice that preform anesthetic procedures on their patients there is an anesthetic monitoring form to assist the staff in recording pre-surgical medications, induction agents and vital signs live time before, during and after surgery from any device. 

Click on the Anesthetic Monitoring Form link from the Medical Record Quick Links box and if a weight has not been entered if prompted after a certain amount of that has passed, the system may prompt for a weight. Enter weight is prompted then click "Save and Go to Anesthetic Monitoring" and the anesthetic monitoring form will be generated.

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If a weight does not need to be entered the anesthetic monitoring form will be generated.

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*Note: Defaulted pre-meds, induction agents, emergency drugs and fluids can be added to automatically generate when an Anesthetic Monitoring Form is added.

 

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