How to keep meticulous medical records


It's difficult to document everything in a medical record and even harder to know who should do it and when. Cut out the guesswork with these guidelines.

Medical records play an integral part in client and pet care. They're primarily intended to benefit patients by recording the care recommended and provided. They also serve as legal documents in court. So it's important to keep records accurate and up-to-date. But just who needs to log what when? Here's the answer—regardless of whether your practice is paperless or paper-heavy.

What: Client and patient details (name, mail and e-mail address, phone numbers; pet name, reason for visit, species, breed, age, gender, reproductive status, color, distinguishing markings, microchip)

Who: Receptionist

When: For new clients, collect all this information when they initially schedule appointments, then confirm it when they arrive. Verify existing clients' contact information when they schedule a visit, and, if they make their next appointment before leaving the practice, double-check their contact information before they head out.

Why: Clients appreciate when you greet them and their pets by name. For drop-off or hospitalized patients, you must collect owners' information in case you need to contact them for an emergency, and doing so as soon as clients walk in the door ensures you remember. An accurate address is essential for billing purposes as well as for follow-up contacts, such as reminders. Patient details also allow veterinarians to prepare and, later, help ensure appropriate treatment.

What: Patient history (chief complaint, symptoms, other household pets, travel plans, lifestyle)

Who: Technician or assistant

When: If clients call with emergencies or sick pets, ask them over the phone about the chief complaint and symptoms. For wellness patients, collect these details at the start of the visit. Also note changes in pets' conditions on arrival.

Why: This information enables team members to give doctors advanced notice of potential illnesses, how serious the symptoms are, and whether the pet's health is deteriorating or improving. It also helps the team determine which topics are most important in terms of client education.

What: Examination results (weight, temperature, pulse and respiratory rate, mental state, conformation, hydration status, complete systems review)

Who: Technician or assistant

When: As learned, throughout a hospitalized pet's stay, and on discharge

Why: These medical markers illustrate whether the patient's condition is improving or deteriorating and help determine diagnosis and treatment.

What: Assessment, differential or definitive diagnosis, recommended treatment plan, diagnostic recommendations and outcomes, and any consulting specialists' reports

Who: Veterinarians; technicians may be responsible for recording some diagnostic results

When: During the appointment or immediately following

Why: These details help determine diagnosis and treatment, ensure clients get vital pet-care information, and assist the veterinarian who sees the pet in the future.

What: Documentation of client's informed consent and acknowledgement of risk

Who: Technician or assistant

When: Before the appointment ends

Why: When appropriate, this ensures clients have been educated about the necessary treatment course and protects the practice from liability.

What: Treatments performed and therapy administered (vaccinations, drug names, dosages, routes of administration including anesthetics)

Who: Technician or assistant

When: During the appointment

Why: Documenting this ensures that pets receive the best possible care and that clients are aware of what's happening.

What: Results of treatments and daily narratives of hospitalized patients' conditions, assessments, changes in therapy, and discharge date

Who: Technician or assistant

When: Every day

Why: Clients need peace of mind. These details also allow veterinarians on various shifts to easily see which treatments pets have received and how to proceed.

What: Recommendations for preventive medicine, outpatient care, follow-up visits, and postoperative instructions

Who: Veterinarian

When: Doctors must record recommended preventive care and follow-up visits before wellness visits end. They must record inpatient and outpatient follow-up care before the pet is discharged.

Why: Reading recommended preventive care and the suggested schedule of follow-up visits allows team members to educate clients appropriately, reinforce recommendations, and make future appointments before pet owners leave. The information is in the record if clients request a copy. And it's also readily available in case there's a problem after discharge.

What: All client communications (in person, over the telephone, via e-mail)

Who: Receptionist, technician, assistant, practice manager, and veterinarian

When: Immediately after the communication takes place

Why: Even if a team member simply leaves a voice mail for clients, co-workers need to know. This ensures pet owners receive the necessary information and helps the practice avoid the embarrassment of duplicate contacts and providing clients with conflicting information.

Ultimately, there's no such thing as too much information when it comes to medical records. (If the veterinarian is the biggest offender in terms of not filling out the records completely or in a timely fashion, search for "doctor record compliance" to read suggestions for what you can do.) Remember that adequate records should list all clinical information pertaining to the patient, including sufficient detail to justify the diagnosis and treatment. To fix all your medical record problems, follow this basic rule: If it happens, write it down.

Paige Phillips, RVT, is a Firstline Editorial Advisory Board member and chief of operations at the Veterinary Specialty Hospital of the Carolinas in Cary, N.C.

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