Visit / Discharge Report
VTH Policy #MR207
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.
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.
- 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)
- At patient registration, a blank Visit Report is created.
- 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.
- The Report is used to document appropriate information during the patient visit.
- The Report is updated prior to patient discharge to include template information.
- At discharge, the Report is printed and provided to the owner or sent via email by accessing the SEND screen in the HIS.
- At discharge, the student or clinician will send the Report to the rDVM by accessing the SEND screen in the HIS.
- 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.
- The finalized Report shall be sent by the clinician to the client and rDVM via the SEND screen.
- rDVMs may access additional patient visit information, including laboratory results and reports, through the rDVM portal.
- Reports finalized in error, must be retracted by contacting Medical Records firstname.lastname@example.org (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.