6.3 Medical Record and Disease Terminology
Medical Record
A medical record is a compilation of all the documents and information about a specific patient. This includes examination notes, all communication with the client, diagnostic test results, surgery reports, prescriptions, and more. Provincial legislature regulates what is required to be in the records and determines the quality standard that must be met. Medical records are very important for patient care and clinic integrity (ABVMA, n.d.).
For your role in maintaining medical records, it is important to be familiar with your clinic’s operating procedures. You must understand the general layout of the medical record so you know where to find information.
SOAP Notes
One of the most common formats for writing a medical record entry for an appointment is the SOAP format. SOAP stands for subjective, objective, assessment, and plan.
Subjective: “Non-measurable” information: The presenting complaint and history from the owner
Objective: “Measurable” information: Temperature, pulse, respiratory, weight, CRT, and generally all physical exam results
Assessment: Evaluation of the subjective and objective data to determine the health of the animal, the severity, and any diagnoses or differential diagnoses
Plan: The steps moving forward for the treatment or diagnostic testing of the pet
Exercise
Where do you look??
Common acronyms in the medical record and where they are often found
MR: Medical record
Subjective
- Hx – History
- Vx – Vaccine/vaccination
- CS – Clinical signs
- O – Owner
Objective
- PE – Physical exam
- BP – Blood pressure
- CV – Cardiovascular
- GIT – Gastrointestinal
- HR – Heart rate
- RR – Respiratory rate
- T – Temperature
- TPR – Temperature, pulse, respiration
- CRT – Capillary refill time
- MM – Mucous membranes
- ROM – Range of motion
- BAR – Bright, alert, responsive
- BCS – Body condition score
- WNL – Within normal limits
Assessment
- Dx – Diagnosis
- DDx – Differential diagnosis
Plan
- Bx – Biopsy
- Rx – Prescription
- Sx – Surgery
- Tx – Treatment
Signalment Terms
Signalment, as discussed earlier, is a description of the patient which includes species, breed, age, sex, and reproductive status. The following are some terms and their associated abbreviations you might see in this section.
- Species
- Will generally be written as canine, feline, equine, etc.
- K9 – canine
- Breed
- Will be provided by owner
- Age
- Owner will provide date of birth or approximate age (rescued pets might have approximate ages)
- Age generally given in years (y/o – years old), or months if the pet is under 1 year of age
- Sex and reproductive status
- Generally written as male or female
- Reproductive status for cats and dogs written as neutered or intact for males and spayed or intact for females
- F/S, FS – Spayed female
- M/N, MN – Neutered male
- Reproductive status in large animals might be written as castrated or intact for males, and generally females do not have gonads removed unless medically required
- A term that combines sex and reproductive status might be used, such as stallion for a male uncastrated horse
Example Signalments
“Fluffy” Dumont – 2 y/o, K9, MN, miniature poodle
- Age: 2 years old
- Species: Canine (dog)
- Breed: Miniature poodle
- Sex: Male neutered
“Suzie Q” Smith – equine, 8 y/o, thoroughbred, mare
- Age: 8 years old
- Species: Equine (horse)
- Breed: Thoroughbred
- Sex: Female intact
Note: When writing out a patient’s name, we often add quotation marks (“”) around the animal’s name, then write the owner’s last name.
Disease-Associated Terms
Throughout the medical record, you will likely find reference to terms that are used to describe diseases. It is important for you to understand what these mean so that if clients ask questions, you are able to translate the “vet-speak” into terms they can understand.
Disease Onset and Cause
Clinical signs: Observable differences in an animal
- Examples: Increased drinking, increased eating, lethargy, vomiting
- This is often termed “symptoms” in humans. However, we cannot use that term in veterinary medicine because our patients cannot tell us how they feel.
Asymptomatic: When a patient is not showing any clinical signs
- Animals who are infected with a disease and are contagious but are not showing clinical signs are called asymptomatic carriers.
Acute: Rapid onset of a condition
Chronic: Ongoing condition that continues over time
Diagnosis: Cause of disease
Differential Diagnosis: Potential cause of disease
- Veterinarians will often form a list of potential causes of the clinical signs and try to determine which of them is the true cause. In this brainstorming phase, these potential causes are the differential diagnoses.
Idiopathic: Disorder of unknown cause
Iatrogenic: Disorder occurring as a result of medical treatment
- This can include negative side effects of medications
Describing the Disease
Pathogen: An organism that causes a disease
- Some examples are bacteria, yeast, fungus, mould, virus, parasite, or prion
Transmission: Transfer of disease between animals
- Routes of transmission (how a disease is transmitted) include direct contact, fecal-oral, blood-borne, air-borne, sexual, and via fomites.
- Fecal-oral: Transmission occurring when infected feces are ingested by another animal
- Fomite: Object that can harbour disease which then infects another animal
- Example: A farmer walks through a pen, and pathogens stick to their boots. When they enter another pen, the animals in the new pen are exposed to the pathogen from the boots.
Infectious disease: Disease caused by organisms such as bacteria, viruses, fungi, or parasites (Mayo Clinic)
Non-infectious disease: Disorder not caused by organisms
- Examples: Trauma, congenital, iatrogenic
Contagious disease: Disease that can be spread between animals either directly or indirectly
Non-contagious: Disease that is not spread between animals
Subclinical: Animal is infected with the disease but is not showing clinical signs
Zoonotic: A disease that is transmissible between humans and animals
Describing Cancer
Just like humans, pets can develop cancer. There are many different forms of cancer–one trick to recognize if something is referring to cancer is by looking at the suffix. The suffix “-oma” refers to a mass or tumour, so generally anything with that suffix relates to a tumour that could potentially be cancerous. The word cancer has a bad reputation, but it does not always describe a life-ending disease. Therefore, be careful when using this term with clients.
Neoplasm: New growth
- Often described to owners as a lump or a mass
Benign: A mass described as benign is unlikely to spread to another area of the body, invade neighbouring tissue, or cause rapid onset of problems
Malignant: A mass described as malignant is more likely to spread to other areas of the body, invade nearby tissue, and cause serious problems
Metastasis: When cells from a mass spread through the bloodstream to another area of the body and start forming new masses there
- Example: When a dog is diagnosed with osteosarcoma (malignant bone cancer), veterinarians will often take x-rays of the lungs to see if there are masses there that have spread from the bone.
Describing Outcome
Prognosis: Prediction of the outcome of the condition. Generally ranges from excellent to terminal, where an animal has an excellent chance to recover fully vs. an animal will most likely die from the disease.
Recover: Become healthy again
Palliative: End-of-life care focused on keeping a patient comfortable rather than curing their disease
Supportive care: Care focused on treating clinical signs rather than curing a disease
- This might be done if there is no specific treatment for a disease, or if further diagnostics and treatments are refused by the owner.
Exercise
Attribution
Unless otherwise indicated, material on this page has been adapted from the following resource:
Betts, J. G., Desaix, P., Johnson, E., Johnson, J. E., Korol, O., Kruse, D., Poe, B., Wise, J. A., Womble, M., & Young, K. A. (2013). Anatomy and physiology. OpenStax. https://openstax.org/books/anatomy-and-physiology/pages/preface
References
Alberta Veterinary Medical Association (ABVMA). (n.d.) Medical records handbook. https://www.easav.ca/upload/files/MedicalRecordsHandbookFullColor%20(1).pdf
Mayo Clinic
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