Medical Record Forms & Templates

Implementation Date: 9/24/2009

Date of Last Revision: 4/2013

Next Review Due: 4/2023

 

Reviewed by VTH Administrative Team: 3/2013

Reviewed by VTH Board: N/A

 

Reviewed by VTH Section Heads: 3/2013

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Section Heads without approval.

Policy

All forms (templates) used in the medical record, whether electronic or paper, shall be reviewed and approved by the VTH Director’s office.

Guidelines

The forms or templates need to be standardized for ease of use, clarity of purpose, to reduce legal liability and provide a minimally necessary database of information.Forms or templates shall be reviewed for adherence to VTH policy, and other standards such as Illinois Veterinary Practice Act, AAHA, AVMA, COE, etc. 

Procedure (if applicable)

1. Additions or revisions of VTH Medical Record forms or templates shall be submitted to the Health Information Systems Process Analyst for review along with the following information:
   • the purpose or use of the form or template
   • who may complete the form or template
   • when the form is to be completed (e.g., upon admission, at discharge, etc.)
   • who is the intended recipient of the information (e.g., the owner, referring veterinarian, or just for the record)
   • who may e-sign the report, including whether or not it must be co-signed by a faculty veterinarian if allowed to be completed by a non-faculty veterinarian
   
   
2. These recommendations are then provided to the VTH Director for approval.After approval the hospital will be notified of its availability, purpose and authorship rules. The form will be added to the orientation guidelines.

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.