Computerized Medical Health Records

Jefferson Animal Hospital is Accredited by the American Animal Hospital Association and we subscribe to extremely high standards for the benefit of our patients.   We are required to maintain detailed computerized records that can be accessed by both our hospitals at any time if your pet is seen for emergencies or continued care nursing or examinations.  Our practice maintains records in such a way that any of our veterinarians may be able to proceed with the continuity of care and treatment of your pet.  You can access your pet’s medical wellness notes on PETLY.

Our medical records are typed and legible and each patient’s response to care is documented.

Our medical records allow for easy retrieval either manually or electronically.  Consistent patient identification methods are used on all records.  Problem oriented medical records logically document chief complaint, patient history, physical examination results, assessment and plan.  Each patient has a separate medical record.

All our records reflect owners name, address, telephone, alternative telephone if necessary, and email if applicable. Patient record reflects pet’s breed, DOB, Sex, Markings, microchip or tattoo for accurate ID.  Immunization history is easily retrievable and schedule for future immunizations.  Our patient’s weight is accurately recorded for every presentation. The author of medical notes is uniquely identified.   Procedures are presented in chronological order with accurate examination findings, tentative diagnoses, therapeutic plans, medications administered/dispensed, and all communications with you, our client.

Accurate descriptions of surgical procedures, and anesthesia is noted along with reports and assessments of diagnostic procedures such as lab tests, imaging or cytology. All signed consent forms are recorded along with documented medical history including previous problems, treatment and responses, prior surgeries, medications, diagnostic tests, current medications, environmental history, client observations and current diets.

Your pet’s medications are identified with name, date, dosage, route, frequency and duration.

Medications are identified with individual who administered the item and the practice provides summaries or copies of medical records when requested by you, the pet owner.

Our practice utilizes a written protocol noting who can write in medical records, confidentiality and authority to access the information.  Our practice utilizes written protocols for patient discharge.   Our practice discusses with you, our pet owner, the potential benefits of recommendations, problems related to patient recuperation, possible results of non-treatment, significant alternatives to recommendations and financial responsibilities for the patient.

Written discharge instructions are given to you and copies maintained with the medical records.

Electronic medical records are maintained securely with adequate back up methods.

The author of our record entries is always identified.

All of this is to make sure your pet receives excellent medical care that can be documented for follow up exams or when another veterinarian examines your pet.   This is all good for both you and your pet(s).