SANDI - SOP for Updating rDVM in the Patient Medical Record

This article outlines the process for adding, updating, and correcting rDVM information within the Patient Edit screen as well as the Registration Screen.

Definitions

  • rDVM – Referring Veterinarian
  • ROI – Release of Information
  • HIS – Health Information System

Please select the appropriate scenario for detailed instructions:

rDVM entry when creating a new patient 

  1. If the rDVM is known, enter it.
  2. If the rDVM is unknown, leave Referring Vet line blank/empty.
    1. Note: Do Not enter NO RDVM or Confirm RDVM.

    rDVM entry when the patient already exists 

    If the patient already exists but does NOT have any prior visits, the rDVM can be added directly to the patient edit screen.

    • Open the Patient Edit screen and enter the rDVM on the Referring Vet line. 

    rDVM entry at Registration 

    If the client is present and the patient is being registered AND

    No rDVM information exists for the patient:

    1. Ask the client if they have an rDVM for our records and enter that information on the Registration screen for the current visit.

     An rDVM is listed for the patient:

    1. Verify that the current rDVM listed is the rDVM they would like us to share information with from this visit.
    2. If the client requests a different rDVM, change it on Registration Screen.

    Immediately following the visit registration process the client indicates they would like a different rDVM:

    1. Utilize the Visit Edit screen and update. (If a visit report has been started email medrec@vetmed.illinois.edu to update records.)

      rDVM entry during or between visits

      Changes requested during a patient's(in-patient) stay"

      Note: In-patient records should be changed by Med Rec because the rDVM must be updated on the visit reports in addition to the patient and visit screens.

      Changes requested in between visits from the currently listed rDVM to a different rDVM:

      Note: Medical Records will reach out to the owner to complete a release of information form (ROI) from client.



      Keywordsrdvm, refer, referring, update, change, patient, client, clinic, doctor,   Doc ID129412
      OwnerTina O.GroupUofI College of Veterinary Medicine Teaching Hospital
      Created2023-06-29 10:59:48Updated2023-06-29 11:50:31
      SitesUniversity of Illinois College of Veterinary Medicine Teaching Hospital
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