Title: Maintain veterinary records.
Course: Veterinary Science I (18105-I) > Section: Performing Office Functions

Maintenance should include

- explaining the types, purposes, organizational principles, and legal aspects of veterinary medical records, including state-specific retention requirements
- explaining the importance of accuracy and consequences of inaccuracy, such as medical errors, legal liability, and compromised patient care
- describing file systems and management including paper-based, electronic medical records (EMRs), and hybrid systems
- applying principles of file management according to accepted practices
- identifying information included in veterinary records such as SOAP (subjective, objective, assessment, plan) notes, consent forms, diagnostic reports, and treatment plans
- setting up and keeping accurate, up-to-date, legible, and complete records
- explaining the importance of maintaining confidentiality of all information in compliance with legal and ethical standards.

Process/Skill Questions:

- Why do veterinary records need regular maintenance? Why is it important to update client records after each visit?
- What are various ways to organize records? What are the advantages and disadvantages of each?
- What environmental factors should be considered when storing paper files? Why?
- What could be consequences of not maintaining confidentiality of veterinary records?