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Dr. Kevin Fitzgerald: Write it down


In this week's blog, Dr. Fitzgerald advises keeping thorough medical records.


Write it down

Recently, a well-known, competent veterinarian who has been in private practice for many years was brought before the state board for medical malpractice. Like many of us, he had a difficult case that had an outcome that was not at all desired. His front desk staff and technicians all gave their accounts on his behalf, attorneys on both sides argued their cases, and the aggrieved family had their say. Sadly, the most damning evidence against the clinician came in his own handwriting. In the seized record, the documentation regarding the case—history, clinical signs, rule-outs, and diagnostics—were all summed up in only one word, “pyometra.”

Would you be embarrassed if your records were seized and read aloud in a court of law? Make no mistake. The medical charts you write in every day are a legal record. They document every aspect concerning an animal's medical case. There are not many plaintiff veterinarians sitting around saying, “I wrote too much” or “I documented the case in too much detail, included too many observations, test results, and client conversations.” On the contrary, state board conference rooms, courtrooms, and attorney's offices are full of veterinarians thinking, “If only I had that one back. If only I had the documentation to support my side.”

There is a wise saying regarding the practice of medicine that we should pay serious attention to: If it isn't written down, it didn't happen. We are all busy; we all have heavy caseloads and hectic schedules. Are you too busy to protect yourself or to document the care that you provide to your patients? Is it just the time required to do it, or do you have a self-destructive side? Maybe you enjoy attorneys asking you questions or talking to the representatives of insurance companies? If so, all right. However, for the rest of us, here is some sound advice: Write it down. The legal record includes the history, clinical signs, differential diagnoses, a list of diagnostics run (and their results!), and any treatments and therapeutic regimens that are undertaken. Any estimates given should also be included with the record. Any communications with clients need to be noted. Hospitalizations should be well noted for the duration of the stay, and medications given should be closely listed. Home care instructions and treatment regimens should be entered into the record as well. This is not just to help you, the clinician; this will also safeguard the animal from having medications skipped, given twice, or ignored entirely.

So, for your next case, check yourself. Would you be embarrassed if your notes and records were read aloud to the client? How about to a state board committee? How about a jury? Detail everything that you think and do. Don't be your own adversary, your own hostile witness. Document all that you do.

See you next week, Kev

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