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Vetstar - Medical Record Documentation (Visit Report, Image Uploads, SOAP Notes, etc.)
When a patient is registered in Vetstar, a report titled “Visit Report” will automatically be created. A visit report should be created for all patient visits including suture removal, bandage changes, and visits where the patient dies. The only exceptions are lab work only (where the patient is not seen), and outpatient imaging. The patient visit report is printed for the owner at the time of discharge and is sent to the rDVM. Typically a Visit Report is started by a student and then an Intern or Resident will finish the report. Finally a faculty or Resident will verify the report.
Video Training Link: Electronic Medical Record
Examination Medical Record Documentation Process
- From the Vetstar home screen, ensure that you bring up the current client/patient.
- Enter ex or emr at the Command line and press Enter.
- If it is the first time the patient has been seen it will bring you directly to a list of reports that are available. If the patient has been see before you will see the Patient Visit Selection Screen which lists all fo the visits. Select the correct visit you want to add documentation to.
2. Select the visit by double clicking on the current visit (a prior visit can be select if you need to write an old visit report). This action tells Vetstar what visit you want to “file” the documentation in.
3. Select the Patient Visit Report by clicking in the box next to the status.
4. After selecting the Patient Visit Report, choose the service area seeing the patient.
5. After selecting the service area, those templates associated with that area will display.
- Typically you will choose a Visit or Discharge template for that specific service. Some services may have additional report templates, the vet tech in your service can help guide you on what to choose if needed.
- You can also select a signature and it will bring that individuals signature to the bottom of the report.
- Select on the checkbox(s) next to the desired template(s), and then select Save. on the Verify Templates button or press Alt/y.
6. Wait for the editor to be populated with your templates and then you can being to text to complete your report.
**Save your work Frequently**
- The flashing lightning bolt icon at the bottom right of the Vetstar program will flash red while processing, then change to solid yellow.
- Click three (3) times to select a check box.
- Add notes next to any selection box where there is an abnormality.
- You will see the signature we added at the bottom. If needed move it to the proper place in the template.
- You can copy and paste by right clicking in the editor and choosing the appropriate action. (ctrl+c nor ctrl+v work)
7. If you wish to add more templates to the report, you may re-access the template group area by clicking on the template button found on the right side of the editor.
- There are several services that have templates with additional text that they add to the visit report. These could be instructions on preventative care, how to manage a bandage, or medication instructions.
- Once you've selected additional templates you can right click to select the text and move it anywhere in your template.
8. After completing the visit report the final step is to Verify (e-sign) the visit report. This can be done by going back into the template and selecting Verify and entering your PIN. If you need need your supervising clinician to verify, and they are readily avail be, they can just review the template and select verify and enter their PIN directly from your session. If they are not available, select Save and alert the supervising clinician that they need to verify the report.
Note: Notice that the report Description has now changed to match the service template you chose.
Other Medical Record Documentation (Similar to the Visit Report)
The emr screen is what all medical record documentation is created. There are many forms in Vestar, the vast majority used are:
- Visit Reports
- Consult - some of these generate an email to the service stating that the patient is waiting for a consult. (If you select this by mistake please alert the service that a consult is not actually needed.)
- SOAP Notes - A new SOAP should be created every time you workup the patient. If you examine a patient multiple times in a single day you should create a new SOAP form after each examination
- Surgery Reports
Adding a Form
Example of SOAP Note Form addition and Template
Creating an Uploaded Document (pdf, jpg, etc.)
- To start another report access the reports screen by typing the quick command ex or emr.
- Select the appropriate visit to “file” the documentation.
- Click on the Add form
- Select the type of form you would like to upload.
- Select Upload More
6. You will be prompted to enter your NetID and password for 2-Factor Authentication and then be directed to an upload screen.
7. Select the Add Images (+button)
8. Select Choose Files
9. Go to the location of the saved image copy the document you wish to upload and select it.
10. Submit & Finalize if you have permissions or Submit for a clinician to finalize later.
11. Now you can go back to Vetstar and select the image file You can rename the document by typing the name where it says uploaded image and then save
Example of a Rename and view of the image.
Offsite Zoo Reports
These are sent to medical records by Zoo Med. Medical Records then uploads the reports into the patients electronic medical record.