Web Chapter 8 The pet’s medical record may be broader than sometimes appreciated. For example, “registration forms, consent forms, radiographs, estimate sheets, billing records, telephone consultations, controlled drug logs, laboratory results, surgery reports, discharge records, imaging recordings, patient history, treatment records, and consultation reports” all may be considered part of a pet’s medical record (Scott, 2006). Specific suggestions of facts to include in the medical record when animal cruelty is suspected are: “[w]henever nonaccidental injury is suspected, the attending veterinarian should obtain a minimum database, including estimated age, an accurate body weight, and a body condition score, and should perform a complete physical examination, a thorough oral examination to establish the condition of the teeth, otoscopic and ophthalmic examinations to identify potential head trauma, radiographic examinations to rule out occult injuries, and other species-specific examinations as necessary” (Babcock and Neihsl, 2006).
Small Animal Poisoning
Additional Considerations Related to Legal Claims
Medical Records
What Should Be Included in Medical Records?
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Chapter 8: Additional Considerations Related to Legal Claims
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