Record Creation & Fees
| Implementation Date: 07/23/2009 | Date of Last Review: 4/6/2023 |
Next Review Due: 04/5/2026 |
| Reviewed by VTH Administrative Team: 03/2013 | Revised VTH Section Head Approval: 04/2013 |
| Reviewed by Legal Counsel: N/A | Presented to VTH Section Heads: 03/2013 |
Subject to modification by the VTH Director without approval.
Policy
A medical record (paper or electronic)is generally created and a New Patient Record Fee charged, for patients presenting to the Veterinary Teaching Hospital or seen in the field.
Guidelines
INDIVIDUAL ANIMALS
Small Animal: Where multiple healthy animals from the same owner are presented for vaccinations, CERF (Canine Eye Registration Foundation) exams, OFA (Orthopedic Foundation for Animals) exams (Hip) etc. each animal is assigned its own individual record number and each assessed a reduced record fee.
Animals born in the hospital will each be assigned an individual record number and each charged the Additional Animal New Patient fee.
Any unhealthy animal brought in as part of a group (i.e., the sick animal needs to be separated from the group) will be assigned an individual record and charged the New Patient Record Fee.
Equine Species: (Includes horses, donkeys, mules, ponies, zebras etc.). A patient that is presented as a companion to one being treated or in the case where an animal(s) is born in the hospital will be assigned an individual record and charged the Companion/Born-in-Hospital fee. If a horse presents to the VTH that was previously only seen as part of a Field Service record, the horse is now assigned an individual medical record and assessed a New Patient Fee.
If a potential buyer of a horse presents for a pre-purchase exam, the horse is assigned a new medical record number (even if a record exists already) under the buyer’s name and is assessed the New Patient Record Fee.
Non-Equine: (Includes cattle, sheep, goats, swine, alpacas, llamas etc.). A patient that is presented as a companion to one being treated or in the case where an animal(s) is born in the hospital will be assigned an individual record and charged the Companion/Born-in-Hospital fee.
Food Animal Foot Trims: Each animal is assigned an individual record. One patient will be charged a regular new record fee. Each additional animal will be charged the Additional New Patient Record Fee.
If an individual food animal presents to the VTH that was previously only seen as part of a Field Service record, the animal is now assigned an individual medical record and assessed a New Patient Record Fee.
MULTIPLE ANIMAL RECORDS
Small Animals: Healthy litter or group presented for tail docking or dew claw removal should be charged one (1) new record fee and be assigned one medical record number.
There is no new record fee when a healthy litter that is not here for medical care, is accompanying an unhealthy mother.
Food Animals: A group of healthy animals presented for certain simple elective procedures (i.e., dehorns, castrations, nose rings, pregnancy checks NOT A.I. [artificial insemination]) should be charged one (1) new record fee & be assigned one medical record number.
For those patients seen on the premise (field service record) one medical record number is assigned for each location and is charged a new record fee.
If a horse, dog or cat is seen on the premise (field service record), each is assigned an individual medical record but not charged a new record fee until presented to the Veterinary Teaching Hospital.
LAB WORK ONLY
Patients presenting to the VTH only for laboratory tests will each be assigned an individual record and charged the regular New Patient Record Fee. In cases where samples are from production animals, the farm medical record may be used.
NECROPSY OR DEAD ON ARRIVAL (DOA)
In general, dead animals are not accepted for necropsy or disposal where there is no previous client-patient relationship. However, if the animal is accepted, a medical record number will be assigned and a new patient fee assessed The patient’s permanent ID or name shall be used in the patient name field in the health information system. Sex, Breed, DOB if known should be entered.
For Large Animal/FARMS patients presenting to hospital that have only been seen on farm, a patient will be created in HIS naming the patient with the format of necropsy year and date (example: Necropsy20201231)
DRUGS AND SUPPLIES
Drugs and Supplies sold for specific VTH patients are to be sold under that animal’s Medical Record Number. If the patient is a VTH employee’s personal animal, and the patient has not been seen by a VTH service, a medical record number and new patient fee shall be assessed.
In cases of production animals, the Field Service record should be used. In cases where the client is a business, institution, or campus researcher a “Drugs and Supplies” patient may be used however, no medical record number is to be assigned.
RESEARCH
University-Owned Animals: Patients used for research purposes that are University or Institutionally owned will not be assigned a MR number unless the animal becomes ill and is examined or treated in the VTH, or the researcher utilizes VTH services for a healthy animal, such as Imaging studies, etc. In this case the patient will be assigned an individual medical record and charged a New Patient Record Fee.
Animals owned by private citizens: Patients presenting to the VTH for research purposes or as part of a Clinical Trial will be assigned an individual medical record and charged a New Patient Record Fee.
TEACHING
Privately Owned Animals: Patients may present to the VTH as part of a course or for an Enhanced Learning Experience.
Class: If the patient is participating as part of a Class, then a medical record is not assigned. However, for the Large Animal Junior Surgery Castration Clinic, an individual medical record is assigned and the patient is charged a New Patient Record Fee. For animals used in the Small Animal Surgery courses, (Jr and Sr Surgery animals from shelters) no new patient fee will be assigned.
Enhanced Learning Experience: If a patient presents to the VTH for students or house officers to gain additional skills or hands-on experience an individual medical record number is not generally assigned, e.g. intern exotics lab.
University Owned Animals: Animals boarded in the hospital for teaching purposes are assigned a medical record number and assessed a New Patient Record Fee.
BLOOD DONOR SCREENINGS
Animals presenting for screenings that have not yet been accepted into the Blood Donor program will not be assigned a Medical Record number. Once accepted they will be assigned a Medical Record number and assessed the New Patient Record Fee.
WILDLIFE WARD ANIMALS
Animals in the Wildlife Ward are not assigned a hospital Medical Record number unless they present to the hospital for diagnostic testing or for prescriptions. The number assigned is “WW” followed by the Wildlife ward log number, e.g. WW090301. These patients are not assessed a New Patient Record Fee.
Wildlife presenting to the emergency room for euthanasia only, will be assigned a Medical Record number by the Emergency Room in order to track the euthanasia drug fee. This Medical Record number will be assigned as “WE” followed by the next available number, e.g. WE001, WE002.
STRAY ANIMALS
Animals presented to the VTH as a stray, and the owner is unknown, are assigned a chronological stray Medical Record number, e.g. VS001, VS002, etc. The pre-numbered folders are available in the SAC Emergency Room. (These folders are also available for Large Animal strays). These patients are not assessed a New Patient Record fee. However, if the animal owner is located and chooses to have the animal remain hospitalized or treated, the regular Medical Record number will be assigned and the New Patient Record fee assessed at that time. The new record shall have an alias of the old stray number and the records will not be merged.
Procedure (if applicable)
Definitions (if applicable)
Veterinary Teaching Hospital (VTH) – The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.