How to use the Problem Oriented Veterinary Medical Record

            I am a veterinarian specializing in the field of small animal practice. As a veterinarian, it is my responsibility to teach and impart my knowledge with aspiring veterinarians. I am teaching a group of veterinary students on their first patient encounter how to use the POVMR or the Problem Oriented Veterinary Medical Record.

            The field of small animal medicine is one of the most rapidly expanding areas of veterinary science, and veterinary students are now required to assimilate and absorb more factual information than ever before. More importantly, each student must learn how to apply this vast wealth of information to clinical situations which are geared to providing the best possible quality of patient care in terms of diagnosis and management. In this respect the problem-oriented approach, in addition to being an integral part of the diagnostic process is an invaluable educational tool. Whereas older diagnostic systems to a large extent relied on ruling out differential diagnoses based simply on clinical impressions of the case in question, problem-oriented medicine places more emphasis on critical identification of the patient’s problems and an understanding of the pathophysiological mechanisms responsible for each problem, thereby providing the framework for a more logical and structured approach to diagnosis and management, which in turn promotes a higher quality of patient care. By concentrating more on scientific logic rather than hunches, the problem-oriented approach eliminates much of the guesswork and discourages hasty and misguided presumptive diagnoses. It ensures that the clinician, having accurately identified specific problems, then places them in proper perspective and investigates them accordingly. By recording all the problems identified from the history and physical examination, plus any laboratory and/or radiographic findings, a more complete and more reliable, clinical picture is obtained. The primary presenting complaint can be recalled if necessary at a later stage of the investigative process (Dunn).

Technical Description

            The problem-oriented approach emphasizes the need for accurate and complete medical records, and a well prepared medical record is fundamental to the concept of quality patient care. It should record details of the animal’s history, clinical findings and results of ancillary tests. For confined patients, it should chart a daily assessment of the animal’s progress together with plans for further investigations, and should include a discharge summary (Smith). In this respect the medical record serves as an important form of communication between technical and professional staff as well as a source of material for retrospective studies. Finally it should be remembered that a medical record is also a legal document which may be called upon in cases of dispute.

            The components of the POVMR can be divided into four groups; 1) Collection of baseline information (database); 2) Formulation of a master problem list (problem definition); 3) Initial assessment and diagnostic plan; 4) Progress notes (daily assessment, follow-up plans, and discharge summary) (Kehn; Ackerman).

            The database consists of problems identified from the history and physical examination. At the outset the clinician should record each problem separately, regardless of whether or not it appears relevant to the primary presenting complaint (Radostits).

            The master problem list composes the differential, tentative and final diagnosis, the physiological findings, physical examination findings and the findings of the laboratory tests performed (Freedman and Medway).

            The diagnostic plan includes the initial treatment that was given to the animal and the instructions given to client on how to manage the animal upon discharge; may be therapeutic or patient observation.

            Lastly, the progress notes are the information noted when the client comes back for follow-up. The patient’s improvement or if the condition worsens should also be stated.

References:   

Ackerman, Lowell J. Blackwell’s Five-Minute Veterinary Practice Management Consult. 1st ed. Victoria, AU: Blackwell Publishing, 2007.

Dunn, John K. Textbook of Small Animal Medicine. Ed. WB Saunders. China: Elsevier Health Sciences, 2000.

Freedman, Aviva, and Peter Medway. Genre and the New Rhetoric. London & New York: Taylor & Francis, 1994.

Kehn, Robert. Veterinary Office Practices. Canada: Thomson Delmar Learning, 2004.

Radostits, Otto M. Veterinary Clinical Examination and Diagnosis. China: Elsevier Health Sciences, 2000.

Smith, Ronald Dee. Veterinary Clinical Epidemiology. USA: CRC Press Taylor & Francis Group, 2006.