Practice Management

Good Records Are Just Good Medicine

By Tom Rosenthal

Recordkeeping might not be your favorite part of the job, but good records enhance the quality of care, client communication and compliance, which can improve outcomes and client satisfaction.

In addition, they are a veterinarian’s best defense against any legal action and enable a practice to engage in accurate billing and reimbursement. And they are required by law.

“Good medical records are the best defense against client complaints and civil lawsuits. If it’s not written down, it didn’t happen. It’s good medicine and it’s good business,” said Peter Kazakevicius, DVM, an equine veterinarian in Ocala, Fla.

Every horse examined by a veterinarian must have an individual health record documenting the visit. The record contains all clinical information detailing the animal’s history, care and treatment, including medication and test results. If a veterinarian sees multiple horses in a single visit, each patient gets its own medical record.

“There should be sufficient information to justify your diagnosis, determine the health status of your patient, and then warrant any treatments that you’ve recommended, administered or dispensed,” Dr. Kazakevicius said during a presentation at the at the AAEP 70th Annual Convention in Orlando, Fla.

What Does the State Say?
A state’s practice act mandates what makes a record complete.

“You need to know what’s in your state’s practice act, and the only way to do that is to look it up,” said Dr. Kazakevicius, who cited 2 sources to obtain the acts—the American Veterinary Medical Association and the American Association of Veterinary State Boards. The acts are available online and are free to download.

Medical records also require extensive information about the horse and its medical history. All communications, including phone calls, emails, text messages, voice and written memos, and telemedicine interactions are part of the medical record, as well as all videos and pictures of the animal’s treatment.

An important part of the medical record is the inclusion of when a client declines a recommended medication, test or procedure. “Record that,” he said. “That will come back at you at some point in time.

Dr. Kazakevicius stressed that each patient’s medical record must be clear, concise, complete, contemporaneous, legible and timely. By law, each horse’s health record must be completed within 24 hours of treatment.

“Our challenge—as veterinarians working in the field, driving, and looking in on horses—is to go ahead and create and maintain those health records while doing the examination,” Dr. Kazakevicius explained.

He recommended downloading electronic health record templates that can be filled in during the visit and while traveling to the next appointment. This is where the veterinary technician can provide invaluable assistance by compiling the record while the veterinarian is waiting for the next horse to be brought in.

“They’re with us,” Dr. Kazakevicius said. “They’re setting up equipment. They’re helping us with the examination. They’re getting medications drawn up. I suggest figuring out a way to utilize them more in the documentation of the examination.”

He added that when he is driving to the next appointment, he dictates while his technician fills out the medical record on the electronic template. “Utilize all of your support staff,” Dr. Kazakevicius said.

In addition, he said, templates allow the direct input of required information as you are collecting it.

“It makes [the process] systematic and detailed, and it increases the accuracy of your documentation and your examination. It’s part of good medicine and good business. You tend to have better outcomes.”

Ensuring complete and accurate medical records for each patient allows for a systematic and detailed examination and assessment. “It helps you avoid omissions and mistakes, it facilitates quality of care, and it provides for a continuity of care and communication between all the caregivers,” Dr. Kazakevicius added.

Time is a veterinarian’s biggest challenge. As they travel from visit to visit in a single day, it gets harder to remember all of the pertinent facts for each patient, so don’t delay filling out the records, he said. MeV