Protect pets (and yourself) with solid veterinary records

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Don't let careless omissions or missed rule-outs stand in the way of thorough veterinary documentation.

Last week, a client came into my office for a second opinion on her dog that another veterinarian treated for a presumed cardiac problem. I knew the initial attending veterinarian and was familiar with her practice. She was an old-timer—someone who'd been in the field a long time and still followed the loose prescribing and recordkeeping practices of days gone by.

For example, the package of diuretic the client brought in for me to see was labeled "diuretic"—useful information if a little kid spotted the unsealed envelope and mistook the contents for Skittles. Sometime later we got a copy of the medical record for that case, and that's when I knew the condition might be really serious: The diagnosis was "bad heart."

Why it's critical to document

Those of us old enough to remember the TV series Gunsmoke know that in the 19th century medical records weren't all that important. Old Doc took an untold number of bullets out of various parts of Marshal Dillon's body and never wrote down a thing. There were two reasons for that: Doc remembered everything he ever treated his patients for because he had taken care of them since birth. Equally important: Dodge City's only law office was so busy handling the marshal's criminal cases it didn't have time for malpractice cases against Old Doc.

Fast-forward to today's world of widespread medical testing and case referrals, and it's easy to see why documentation is key. So much happens during a veterinarian's relationship with a pet that it's impossible for a veterinarian to remember all the details of a single patient's history. That means quality and thoroughness in recordkeeping are crucial for medical purposes. Details about observations and noteworthy history help the attending veterinarian as he sifts through subsequent lab work and imaging reports. Content created at the beginning of a case is also critical for referral veterinarians who come into the case later. Lost or undocumented thoughts and observations by the original veterinarian can never be retrieved or re-invented.

Specialists who come into the picture after a clinician's initial exam, no matter how skilled, will never be privy to what could be seen at the beginning of the case. Therefore, it is incumbent on all doctors to be thorough in their examination and just as thorough in their documentation of that exam.

The role of medical records today

Why do veterinary law experts make such a big deal about complete and detailed medical records? From a legal standpoint, nothing is more vital than what those records fail to contain. When a medical record is introduced into evidence in a state veterinary board or civil veterinary malpractice case, it's likely that lawyers experienced in spotting medical and surgical indiscretions and experts in the veterinary profession will scrutinize it. These analysts have the benefit of 20/20 hindsight. They already know the dog's vascular malformation was the identified illness or the cat's owner had secretly treated it with ibuprofen prior to its arrival at the clinic.

This allows the plaintiff's team to reverse-engineer the diagnostic and treatment protocol of the doctor initially treating the case. Any diagnostic or case management oversight becomes a glaring omission in the eyes of a cadre of armchair quarterbacks.

Missing rule-outs spell trouble

Sometimes there's a tendency, especially among experienced practitioners, to itemize only a short rule-out list in the medical records. While other causes of the presenting problem might be in the back of a veterinarian's mind, it's sometimes easier to mention only the most likely causes of a medical problem while awaiting blood work and other diagnostics.

The absence of a complete or fully brainstormed initial rule-out list implies to later record readers that consideration of the case was incomplete or superficial. While the thought of anyone critically reviewing a doctor's work may seem unfair, it's important to recall that malpractice trials are about obtaining money damages, not about objective analysis of a veterinarian's clinical capabilities.

It's not the client's responsilbility

I just got two identical certified letters from my dermatologist. He wants me back to check for more pre-cancerous spots on my shoulder like the one he removed last fall. Now does he just want to scare me into coming in so he can bill Blue Cross for a recheck? Maybe. But it's more likely that he wants his records to show how he made the existence of future risk abundantly clear and that he fulfilled any possible existing duty to inform me.

With that in mind, you might want to ask yourself: Do we remind pet owners to refill chronically used medication or to come in for follow-up glucose curves? If your medical records don't reflect that you reached out to clients in these regards, how could you rebut later client testimony that nobody ever made it clear, for example, that medical treatment for hyperthyroidism is an ongoing therapy? If nothing else, well-kept records are a way of protecting you and your practice.

Dr. Allen is president of the Associates in Veterinary Law P.C., which provides legal and consulting services to veterinarians. Call (607) 754-1510 or email info@veterinarylaw.com.

For a complete list of articles by Dr. Allen, visit dvm360.com/allen

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