Vetstar - Medical Record Documentation (Visit Report, Image Uploads, SOAP Notes, etc.)

When a patient is registered in Vetstar, a report titled “Visit Report” will automatically be created. A visit report should be created for all patient visits including suture removal, bandage changes, and visits where the patient dies. The only exceptions are lab work only (where the patient is not seen), and outpatient imaging. The patient visit report is printed for the owner at the time of discharge and is sent to the rDVM. Typically a Visit Report is started by a student and then an Intern or Resident will finish the report. Finally a faculty or Resident will verify the report.

Video Training Link: Electronic Medical Record 


Examination Medical Record Documentation Process

  1. From the Vetstar home screen, ensure that you bring up the current client/patient.
  2. Enter ex or emr at the Command line and press Enter.
  3. If it is the first time the patient has been seen it will bring you directly to a list of reports that are available.  If the patient has been see before you will see the Patient Visit Selection Screen which lists all fo the visits. Select the correct visit you want to add documentation to.

2. Select the visit by double clicking on the current visit (a prior visit can be select if you need to write an old visit report). This action tells Vetstar what visit you want to “file” the documentation in.

PatientVisitSelection.jpg

3. Select the Patient Visit Report by clicking in the box next to the status. 

PatientVisitReportWorklist.jpg

4. After selecting the Patient Visit Report, choose the service area seeing the patient.

TemplateSelectionByServiceScreen.jpg


5. After selecting the service area, those templates associated with that area will display. 

TemplateIndividualSelectionScreen.jpg

6. Wait for the editor to be populated with your templates and then you can being to text to complete your report. 

Helpful Tips:

**Save your work Frequently**

7. If you wish to add more templates to the report, you may re-access the template group area by clicking on the template button TemplateButton.jpgfound on the right side of the editor.

Helpful Tips:

8. After completing the visit report the final step is to Verify (e-sign) the visit report. This can be done by going back into the template and selecting Verify and entering your PIN. If you need need your supervising clinician to verify, and they are readily avail be, they can just review the template and select verify and enter their PIN directly from your session.  If they are not available, select Save and alert the supervising clinician that they need to verify the report. 

Note: Notice that the report Description has now changed to match the service template you chose.

VisitReportDescriptionChgToProperRpt.jpg


Other Medical Record Documentation (Similar to the Visit Report)

The emr screen is what all medical record documentation is created.   There are many forms in Vestar, the vast majority used are:

Adding a Form

1. To start another report access the reports screen by typing the quick command ex or emr.
2. Select the appropriate visit to “file” the documentation.
3. Click on the Add Form AddFormButton.jpg
4. Select the type of form you would like to create and begin entering your documentation.
5. When finished click save or if you are completely finished you can select verify if appropriate.

Example of SOAP Note Form addition and Template

AddingSOAPNotesForm.jpgSOAPNoteTemplate.jpg


Creating an Uploaded Document (pdf, jpg, etc.)

  1. To start another report access the reports screen by typing the quick command ex or emr.
  2. Select the appropriate visit to “file” the documentation.
  3. Click on the Add form AddFormButton.jpg 
  4. Select the type of form you would like to upload.
  5. Select Upload More

CreatingUploadDoc.jpg

6. You will be prompted to enter your NetID and password for 2-Factor Authentication and then be directed to an upload screen.

ImageUploadScreen-SANDI.jpg

7. Select the Add Images (+button) 

8. Select Choose Files

9. Go to the location of the saved image copy the document you wish to upload and select it. 

10. Submit & Finalize if you have permissions or Submit for a clinician to finalize later.

11. Now you can go back to Vetstar and select the image file  You can rename the document by typing the name where it says uploaded image and then save

UploadedImageNameViewScreen.jpg

Example of a Rename and view of the image.

UploadedImageNewNamePhoto.jpg


Offsite Zoo Reports

These are sent to medical records by Zoo Med.  Medical Records then uploads the reports into the patients electronic medical record.