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Medical Records: The Road Map To Quality Care

Medical Records: The Road Map To Quality Care

Medical Records: The Road Map To Quality Care

Leslie Lynette, RVT, CVPM
Leslie Lynette, RVT, CVPM
on behalf of VetMedTeam

$142.50 $ 142.50 $ 142.50

$142.50 $ 142.50 $ 142.50

$ 142.50 142.50 142.50
142.50 $ 142.50 142.50 142.50
Normal Price: $142.50 $142.50


Launch date: 03 Sep 2015
Expiry Date:

Last updated: 19 May 2017

Reference: 160616

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Excellent veterinary medical record keeping protocols are core to the ability to deliver quality care to patients. It is not possible to overstate the value of accurate, clear, and complete medical records. Unfortunately, medical records are often delegated to the "I will do them when I get a chance" pile and important information is either forgotten or remembered incorrectly. Also, even when handled promptly, poor record keeping protocols result in incomplete records that are often hard to read and confusing.

Take an honest appraisal of the record keeping requirements at your practice. What if a number of months after seeing a patient the animal's owner decided to take the practice to court in an attempt to prove malpractice? Would the patient's medical record serve as non-verbal proof of quality care or would it reflect poorly on the practice? Would the medical record help or hinder the practice's defense? Most veterinary professionals have heard that if it is not in the medical record "then it didn't happen." Often it is the gaps in the medical record that speak the loudest.

Medical records provide a road map, from start to finish. Is the path clear, with each step along the way documented and the plan for the next step clearly laid out? Or is it a confusing jumble of halting steps without clarity and focus? Could another professional, totally unfamiliar with the patient, pick up the medical record and immediately understand prior history, testing, differentials, treatments and patient response? Is client consent and client refusal for recommendations legally documented? Does the practice's medical records aid in increasing patient follow-up and client compliance?

Medical Records: The Roadmap to Quality Care is a 3-week course that provides the foundational knowledge needed to develop sound practice protocols.

The audit section of this course requires access to about 10 random patient charts. Submission of the actual records or submitting private information is not required. Instead an audit form is used to submit findings.


On completion of this course the learner will be able to:
1. Recognize basic elements of complete medical records
2. Describe why proper record keeping is important for a veterinary practice
3. List commonly used medical record abbreviations
4. Explain the function and benefit of a SOAP format
5. Recognize compliance issues, and the role of the medical record in improving it
6. Design and implement a medical records audit system
7. List the advantages of electronic medical records
8. Design and implement a successful program to purge and dispose of medical records
9. Identify common medical record violations that occur in veterinary practices
10. Perform correct and appropriate medical record entries
11. Develop appropriate owner consent forms that are tailored to individual cases
Leslie Lynette, RVT, CVPM

Author Information Play Video Bio

Leslie Lynette, RVT, CVPM
on behalf of VetMedTeam

Veterinary medicine is the career path that Leslie chose at a very young age. As a five-year-old child, she rescued baby rabbits from the family dog after it disrupted their nest. Leslie cared for the survivors and sent them on their way when they became stronger. This was the point at which Leslie knew what she wanted to do in life. After eighteen years of clinical experience in managing veterinary patient care as a Registered Veterinary Technician and Certified Veterinary Practice Manager, Leslie feels honored to be able to give back to the profession and to contribute to the development of colleagues in this field.

Leslie has had the opportunity to experience all areas of the veterinary practice. In 1995, Leslie completed an Associate in Applied Science in Veterinary Medical Technology and upon passing the NVTE became a Registered Veterinary Technician. After several years working in practice and a multitude of continuing education, hard work and training, she was given the designation as Practice Manager. In 2001, Leslie began working as the Hospital Administrator for a group of veterinarians that owned several practices, one of which being a 24 hour emergency care center. In 2008, Leslie earned the designation of Certified Veterinary Practice Manager. Leslie has a genuine passion for the advancement of training and education for managers, technicians, assistants and client support staff.

Leslie is married to her high school sweetheart and together they have one vivacious young daughter that keeps them on their toes. Leslie and her family recently lost their beloved dog Chloe after 15 years and now share their home with a curmudgeon old kitty named “Mr. Willis”. When not writing courses for VetMedTeam, Leslie enjoys boating on the lake, photography, stained glass design and spending time with her family.

Favorite Quote: “The definition of insanity is doing the same thing over and over again and expecting different results.” Albert Einstein

Current Accreditations

This course has been certified by or provided by the following Certified Organization/s:

  • AAVSB-Registry of Approved Continuing Education (RACE)
  • 10.00 Hours -
    Exam Attempts: 3
    Exam Pass Rate: 70

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