In this tutorial you will learn how to update a patient’s initial care record.
What is initial care?
The initial care refers to the first 24 hours of care an animal receives after arriving at your center.
Updating a patient’s initial care record
Visit https://www.wrmd.org/signin and log into your account using the username and password that you registered with.
Go to the patient’s record and click on the initial care tab.
On the initial care page, you will see four panels.
- Keywords: Keywords is an optional field that you can use in any manner you choose. Adding a keyword to a patient’s record is a way to tag or categorize the record so it will be easier to find in later search. The keyword naming convention is entirely up to you. For example, if you were doing a West Nile Virus study, and you wanted to tag all patients who come in with West Nile symptoms, you could add a keyword of your choosing to indicate that (“virus”, “WNV”, “WV”, etc.). You can also pre-set keyword terms in the settings area under autocomplete, to make adding keywords easier and more consistent.
- Intake: The data in the intake panel comes from the same fields that were filled in during the admission process, so it is likely that you will not need to update this information. However, you can use it as a reference when you are doing your initial exam — you can see where the animal came from, why it is in your center, and what the rescuer did with this animal.
- Initial Exam: This is a standard form used for nearly all patients and species. You can fill in the fields as you complete your initial exam.
- Diagnosis: In this field you can include any diagnosis you have for the animal – what you know for certain or what you suspect.
- Disposition: Information in this field relates to the animal’s disposition. In the event the animal arrived dead, died, or needed to be euthanized in the first 24 hours, you can include that information here.
Fill in the relevant information based on your exam findings. Make sure you include the examiner’s name(s) and the treatment that would be relevant to the animal’s care.
Click the green Update Patient button.
Understanding the Initial Exam Panel
This is a standard form used for nearly all patients and species.
WRMD makes it easy for you to fill in information. The date defaults to the current date. In addition, the form is equipped with dropdown menus for dehydration, attitude, mucous membrane color/texture, age, sex, and body condition (BCS). In the age field, the dropdown menu lists age in terms of species type, but you can also designate an animal’s age in chronological time.
In the fields delineating the major body parts, the dropdown menu defaults to “Not examined”. As you type the problem into the text box, this area automatically changes to “Abnormal”. If you’ve examined the area and didn’t find an issue, you can choose “No significant findings” from the dropdown menu. You will still be able to type a comment in that textbox, but it won’t change the dropdown menu because WRMD will trust your choice.
In the treatment and comment boxes, you can add any information that would be relevant to to the patient’s care.
In the Examiner field, you should write the name(s) of the person performing the initial exam.
Understanding the Disposition Panel
The disposition refers to the outcome of the animal. Ideally, you wouldn’t want to fill this out during the initial exam, but sometimes you have to, especially if the animal was dead on arrival, needed to be euthanized, or died within the first 24 hours.
You will want to fill out the various fields to indicate the animal’s disposition. WRMD provides dropdown menus, making it easy for you to choose the type of disposition, the date, the transfer type, the release type. You can add the location of the disposition, the reason for disposition, and who performed the disposition.
WRMD also provides boxes for you to indicate if the patient’s disposition was a part of a criminal activity or whether you saved the carcass.