Failure to properly document procedures and exams can result in legal trouble down the road.
It was hectic at the clinic today, and you left for the evening without updating the charts of your last few patients. Oh well. You'll just jot down some notes when you get home or take care of it tomorrow morning. But what if you forget? Leaving just the smallest bit of information out of a patient's record can leave you stranded later on.
Medical records checklist
Douglas Jack, a lawyer and past president of the American Veterinary Medical Law Association, says the law and the courts are moving toward the notion of an "adverse inference" when it comes to medical records. What does that mean? If it isn't written down, it didn't happen.
Say a client sued you for malpractice, and you know you did all you could to help that patient. In court, your word may not be good enough—you'd need to present the patient's medical records as proof. The courts' stance makes it critical not only to do the right thing, but to document that you did the right thing. "In a busy clinic, I often see a failure to document important aspects of the treatment provided," Jack says. This leaves the door open for problems.
However, there is a way to protect yourself. Regular internal audits of your medical records can help you catch your mistakes—and fix them. In fact, records audits are one of the most important things you can do to shield your practice from risk, Jack says. Here's how to conduct them.
First, set a goal to conduct an internal audit at least annually. Next, decide on the date. Have the hospital manager conduct the audit and instruct the veterinarians—both owners and associates—to review the resulting notes and information.
The manager will randomly select a minimum of 10 files to review. Using the checklist shown above, he or she will mark off what each file contains and make a note of what's missing. And here's the bonus: While you're managing your legal risk, you're also benefiting your practice in other ways, Jack says. The audit:
Jack says a common mistake is to write down the wrong dosage. For example, a doctor writes .01 in the record instead of 0.1. If the manager finds a problem in the records, the next step is to correct it. The manager makes the correction and notes the date of the change in the record. Then a doctor initials the correction.
Even though it's after the fact, conducting the audit and correcting problems is always better than doing nothing. "There aren't many issues in law that are black and white—there are lots of shades of gray," Jack says. "But effective veterinary records management is a black-and-white issue. Good records will save you, while bad records will destroy you."