Keep your equine patient records airtight to avoid the examining board

March 7, 2019
Kyle Palmer, CVT
Kyle Palmer, CVT

Long-time dvm360 magazine and Firstline contributor Kyle Palmer, CVT, is hospital manager for VCA Salem in Salem, Oregon, as well as a practice management consultant for a number of other hospitals.

From the physical exam down to questions asked by the client on social mediamanage your veterinary records to prevent (or worst case scenario: survive) examining board inquiries.

Osetrik/stock.adobe.com

Medical record management is a hot topic among equine practitioners. For some practitioners, specifically those who remember when medical records were simpler, proper note-keeping can be a burden and may even inspire resentment.

But this is an issue of protecting yourself from the rightfully watchful eye of each state's examining board and their commitment to ensuring proper care to patients. Can some complaints issued result in a journey down the rabbit hole only to find out that you did everything right? Absolutely. Thankfully, there are ways to address any anxiety you may feel about a board review and to help you sail right through if it happens.

The best way to survive an examining board inquiry is to not have an inquiry against you in the first place. Poor recordkeeping is a component of poor communication, which is a huge factor in client dissatisfaction, including the kind that may cause horse owners to pick up the phone and complain about your care. All of the steps listed below can help you avoid being under inquiry as well as ensure your survival if and when it happens. 

Your state's practice act and the examining board

Most practice acts are kind enough to spell out exactly how you're expected to practice and therefore, describe precisely how to be successful during an inquiry. Unfortunately, some practice acts focus more on companion animals and sometimes even lump in horses with livestock.

This is a good thing. The majority of states are continually reviewing their practice act, trying to keep up with changes in the profession. As such, the examining board can and should be your friend-a resource to clarify things you're not sure about and an avenue to express your opinion about needed industry changes.

The physical exam is everything

Every time you see a patient for a reason that isn't preexisting, or a condition that may be preexisting but hasn't been seen by you in over a year, it's both legally required (in most states) and wise from a practical standpoint to start  the appointment with a complete physical exam. Do the exam. Record your findings. You can set up particular fields to fill out in today's electronic medical records for everything you're required to assess. If these fields are defaults for every visit, it's an efficient means for recording everything that should be in that record. This will always be the first place the examining board looks, and if you did the exam and noted the findings, it's likely to be a good day for you. If this part of your patient record is absent or incomplete, whatever else you did or didn't do will likely be moot. To be more specific, if you fail to perform an exam, the findings could be invalidated by the absence of the supplemental information that supports your diagnosis. 

As the old saying goes ...

Rule No. 1:  If the record doesn't say you did it, then you didn't do it.

Rule No. 2: If you did it and forgot to record it, refer to Rule No. 1.

Recommendations: Record them

It's not just about what you found. It's also about what you recommended. Documenting your recommendations is a reminder to you to make strong recommendations and then to have some proof you talked about these issues if a client later complains.

If you recommend or offer bloodwork, record it. If you recommend radiographs, record it. If you recommend surgery, record it.

There are two things in recommendations that could hurt you under scrutiny: 1) failing to offer or recommend a course of treatment that you should have (at least in the eyes of the client and examining board), or just as importantly, 2) undertaking procedures, diagnostic tests and treatments without permission. Both things matter, and both things are important. Luckily, there's an extremely easy recording template:

“Recommended radiographs of the left hind leg to client. Client declined.”

“Recommended stall rest and medications. Client consented.”

Get used to these phrases and start putting them into your records on a daily basis.

Client communication: Record it

What used to be limited to an in-person exchange or an occasional phone call is now more complicated. Emails, text messages, private messages via social media, non-private questions asked of you via social media, these are all conversations that belong in that patient's record. This can become a logistical nightmare, but might also be the thing that saves you during a board inquiry. As simple as those conversations may be, they can also represent-at least in the client's perception-a recommendation for a prescribed course of treatment.

There are some amazing voice-to-text apps for your smartphone that can make dictation quick and efficient and allow you to cut and paste your oral notes about client conversations. Another option is: Ask your skilled veterinary technician or assistant who's around during your visits to help write down what you find, what you recommend and what the client said.

Most practitioners are far more at risk from an error in documentation than they are for making the wrong diagnosis. Think about where most of your complaints seem to come from. Did the client complain about the fact that you examined a coffin bone problem and thought it was a hoof abscess, or that you took a shortcut and didn't make sure the client understood your assessment, recommended treatment and (most importantly) the potential for something short of success? Maybe the client didn't understand your estimate. Maybe the client didn't understand the resulting charges. These are all examples of ways veterinary professionals can fail in the moment when it comes to client communication and recordkeeping after the fact. 

Some outstanding veterinarians are horrible recordkeepers, and as a result may one day find themselves in the middle of an inquiry (if they haven't already). Less talented veterinarians who are amazing recordkeepers will never run the risk of a review.

As you prepare for your examining board inquiry, or if you just want to avoid one in the first place, remember the following:

Ask the questions of yourself and the client.

Record the answers in the written record.

Proceed accordingly.

Crossed "t"s and dotted "i"s may not be the exciting part of veterinary medicine that you chased into this industry, but they may just be the things that keep you in this industry.

Kyle Palmer, CVT, is a Firstline Editorial Advisory Board member and Hospital Administrator at Lake Grove Veterinary Clinic in Lake Oswego, Oregon. Please send your questions or comments to firstline@ubm.com.