By Tom Rosenthal

Good medical recordkeeping is a veterinarian’s best defense against malpractice, license and regulatory complaints, Cynthia G. MacKenzie, DVM, explained.

“Whether you're a new practitioner or an older practitioner,” Dr. MacKenzie said, “my take-home message is very simple: Document, document, document. I can't say that enough.”

Dr. MacKenzie spoke at the 2022 AAEP Convention. At the time, she was with the AVMA Trust, which has tracked malpractice claims since 1960. In just 2 years, the AVMA Trust program has seen a 13% increase in the number of professional liability claims submissions for all species. “The trust is on track to review more professional liability malpractice claims this year than ever before,” she said.

“We think it's mainly because of licensing boards going to an online form of submission, so it makes it really easy for an angry or upset owner to file a complaint now against a veterinarian's license,” Dr. MacKenzie said.

Equine professional liability malpractice claims are increasing at a rate of about 15% a year, she said.

While equine claims are a small percentage of the total number of claims, they represent the highest payouts, Dr. MacKenzie said, adding that poor recordkeeping is the leading cause for state licensing boards to issue fines.

“In this current environment, veterinarians are under attack,” she said.

“The purpose of medical records is to document the patient's condition and medical care," she added. “It is also there to document your standard of care. It’s part of the continuation of care. Any veterinarian should be able to pick up your medical records, understand the horse’s condition, and pick up where you left off treating that horse.”

The records belong to the practice, she noted.

Items to include in the medical records are written consent forms, anesthesia logs, surgery reports, physical exam findings, diagnostic tests and diagnosis. Record not only what was recommended, but whether the owner accepted or declined the recommendations.

“What our attorneys tell us is those declined estimates are some very powerful pieces of evidence,” Dr. MacKenzie stressed.

Keep any estimates of treatment provided to the owner, as well as proof if the owner declined the proposed procedures with the medical record.

Additional records to keep in a client’s file: Lab results, estimate sheets, and all communications including emails, voice messages, and records of conversations.

“Right or wrong, the quality of care will often be judged on the quality of your medical records,” she said.

Dr. MacKenzie also stressed that records should be accurate, legible and timely. She recommended that the records should be updated on the same day or within 24 to 48 hours. “I know that most of you are running faster than the pace of these racehorses every single day and that it can be difficult to document everything in a timely manner. I totally understand that you're running nonstop all the time.”

However, Dr. MacKenzie said that the longer a veterinarian waits to document treatment and services, the more likely items may be forgotten. After a hectic week, “you're spending your weekend trying to remember, ‘What did I do to that horse, you know, back on Monday?’ And you're likely to forget things,” she said.

Dr. MacKenzie cited the case of a veterinarian who performed a pre-purchase exam on an 8-year-old Warmblood mare in the Northeast. “Historically, the horse had shown some lameness and some intermittent fevers, but on the day of the exam, none of that was seen,” she said. “The buyer was offered bloodwork, but declined. That decision was documented in the pre-purchase exam report.”

Six months later, after the horse was purchased and shipped to the southern part of the U.S., the horse came down lame. The new owner had another veterinarian diagnose the horse with a titer test that showed Lyme disease. “The owner was upset; she retained an attorney and made a demand for the purchase price of the horse,” Dr. MacKenzie said.

Since the veterinarian could document that there was no lameness or fever on the day of the pre-purchase exam and that the buyer declined bloodwork, “the claim was denied and the client was not paid anything,” Dr. MacKenzie said.

Establishing a culture of recordkeeping and documentation also ensures compliance with legal and regulatory standards.
Clients are entitled to a copy of their horses’ records within a reasonable time, which usually is designated within the state’s practice act, Dr. MacKenzie said. “You want to consult your practice act for specifics on what is to be included in the medical record and realize that that's a minimum requirement,” she noted.

Each state’s practice act is different, Dr. MacKenzie said. “Each practice act stipulates certain requirements for recordkeeping from how long you maintain medical records to the minimum requirements that should be maintained. If you haven't read your practice act recently, I would highly encourage you to do so.” She stressed that practice act requirements are constantly changing.

In addition to the state licensing boards, other regulatory agencies mandate good recordkeeping, including the DEA, USDA, the Horseracing Integrity and Safety Authority, and the Performance Horse Organizations.

“This is really the reason why we’re giving this talk,” Dr. MacKenzie said. “Your records are your defense. And it is crucial in the defense of a malpractice lawsuit or a license or a board complaint. This is what it boils down to: Appropriate documentation is not only needed to support your standard of care, but also to protect against false allegations of negligence.”

Not only are there ethical considerations for maintaining good medical records, it is also a good business practice, she said.

Dr. MacKenzie said, “The rule of thumb is if it was not recorded in the record, then it was not performed. If you document well, if you ever need them, your records will defend you.”