Visit / Discharge Report

Implementation Date: 1/2010

Date of Last Revision: 5/2021

Next Review Due: 5/2023

 

Reviewed by VTH Administrative Team: 12/2009

Reviewed by VTH Board: 1/2010

 

Reviewed by Legal Counsel: 1/2010

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Director without approval.

Policy

A Visit/Discharge Report (Report) form must be completed for each patient visit and be provided to the client and referring veterinarian (rDVM).

The Report must be sent, as a DRAFT or completed, to the client and rDVM at time of patient discharge from the Veterinary Teaching Hospital (VTH).

The Report must be finalized within 3 business days, as indicated by electronic signature (e-signed) on the Report, and the updated (finalized) version sent to the owner and rDVM.

The Report is to be used solely as a medical record to provide information pertinent to the client/rDVM that meets AAHA guidelines. 

Guidelines

• The Report must detail the following at the time of patient discharge: 1) reason for visit; 2) diagnosis; 3) medications to go home; 4) therapeutic plan; 5) recommended follow-up instructions.
• The finalized report with all remaining required information included shall then be sent, if not already done at time of discharge, to the client and rDVM within 3 business days.
• A Report is required for patient visits resulting in death or euthanasia of the patient.
• Telephone communications with the client and/or rDVM do not replace the Report requirement. 
• Large Animal Clinic services will adhere to the established timeline but will utilize service appropriate discharge reports.
• Information pertaining to student education will not be included in the Report unless it also pertains to client information.
• The author of the report may be a veterinary student, veterinary technician or veterinarian. Veterinary students shall save the report for clinician review and e-signing within 3 business days of the patient being discharged.
• Reports written by interns, residents, and veterinary technicians will not necessarily require faculty review and e-signing. These exceptions are determined by the service. Medical Records shall be notified of the names of these authorized individuals.
• Reports in DRAFT status will automatically be finalized at seven (7) days from last edit. 
• Changes, retractions, or addendums must be requested from Medical Records once a Report is finalized.
  
  Audits on Reports will be conducted on a regular basis by Medical Records.

Procedure (if applicable)

1. At patient registration, a blank Visit Report is created.
2. The student or clinician accesses the Visit Report in the Health Information System (HIS) and selects the appropriate template for the service receiving the patient.
3. The Report is used to document appropriate information during the patient visit.
4. The Report is updated prior to patient discharge to include template information.
5. At discharge, the Report is printed and provided to the owner or sent via email by accessing the SEND screen in the HIS. 
6. At discharge, the student or clinician will send the Report to the rDVM by accessing the SEND screen in the HIS.
7. If the Report was not finalized prior to patient discharge, the Visit Report should be completed and finalized within 3 business days as described in the policy guidelines.
8. The finalized Report shall be sent by the clinician to the client and rDVM via the SEND screen.
9. rDVMs may access additional patient visit information, including laboratory results and reports, through the rDVM portal.
10. Reports finalized in error, must be retracted by contacting Medical Records medrec@vetmed.illinois.edu (include the medical record number, and reason for retracting the notes for auditing purposes).

Definitions (if applicable)

Addendum: additional documentation added after Report was finalized and attached to the original report in the HIS.

E-Signature (E-Signing): Applying an electronic signature by entering a user name and password to indicate acceptance and finalization of the Report.

Finalized: Report/Documentation has been e-signed and is a permanent part of the patient medical record and is locked from editing.

Retraction: Finalized Report or documentation is removed from view, while maintaining unobliterated document that may be accessed for legal requests. Used for correcting entries finalized in error

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.