Surgery and Radiology Section

CASE RECORD FOR SURGERY

• A medical record, regardless of style employed must contains the following informations to meet legal standards and the requirements of the practice code.
  • Client’s name, home address and telephone number.
  • Work address and telephone number (not required but very useful).
  • Name and full description of the animal (species, breed, sex, neutering status , birth date, color)
  • Medical information.
• Information about the animal’s condition, including reason for the visit.
• Previous treatment history, if any
• Physical examination findings and diagnosis.
• Treatment and medications used (with complete directions)
• Results of laboratory tests, radiograph, ECG, Endoscope etc.
• Progress and disposition of the case.
• Medical record requirements vary among the states. The above information are must to meet out most standards.
• For operation theatres a separate log book should be maintained and it should contain date of surgery, client and patient's  name, anaesthetic protocol used, type of surgery performed and surgeons name.
• This record can prevent confusion regarding the particulars of any surgery performed in an hospital.
• A separate log book should be maintained for radiology unit. It is required to record date of exposure, exposure factors and patients information for every x-ray taken in radiology unit.
• For any surgical procedures (minor or major), anaesthetic procedures (Local/ general) and diagnostic procedures (radiography/ultrasonography/ endoscopy) consent or undertaking should be obtained from the patiet owner.
• The medical record system allows each hospital to design its own sheet medical record/case sheet should have three major parts.
  • Registration
  • History
  • Work sheet