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?