Let the record show... Veterinary record keeping

Medical record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for veterinarians to spend time thinking and talking about. However, it’s incredibly important, and Guild’s claims management experience suggests veterinarians would benefit from learning more about good record keeping.

Records and insurance claims 

Records can impact insurance claims in two ways:

1. Poor records can contribute to a poor or unexpected outcome following treatment, leading to the client complaining and possibly seeking some form of compensation. For example, a dog’s weight was incorrectly recorded in the record due to a simple data entry error. This led to the dog being given a dose of medication which was too high; unfortunately the dog suffered renal damage and died as a result.

2. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence of what took place and why. Poor clinical outcomes and dealing with complaints can be very challenging and confronting. Therefore, understanding how to improve the standard of records really should be a focus.

Why keep detailed records?

1. Continuity of care

It’s not uncommon to hear veterinarians believe they can remember the details of their consultations. However, at Guild we see examples where veterinarians haven’t remembered key aspects of prior consultations and treatment, and this has led to a poor outcome for the animal. It’s therefore imperative to have this information recorded to ensure certainty as to how and why you’ve treated an animal in the past. It’s also important to be sure you refer to the information within the record. Animals can suffer harm when key information is overlooked or forgotten about and they’re therefore not treated accordingly.

2. Regulatory requirement

All State and Territory Veterinary Boards within Australia have some sort of guideline or policy about a veterinarian’s obligations and requirements regarding record keeping. It’s the responsibility of every veterinarian to make themselves aware of and comply with the various codes, guidelines and policies relevant to them. Not knowing is not an excuse for not complying.

3. Defence of a complaint

If there’s an allegation of wrong doing made against a veterinarian, their records are going to be incredibly important. Those records provide evidence of what took place and why. Without this, the veterinarian will be relying on their memory as a defence. Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a veterinarian’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

What to record?

A question many veterinarians ask when it comes to record keeping is, ‘How much detail do I need to record?’ Veterinarians should refer to their relevant Veterinary Board’s information to better understand the detail required in a record. Exactly what to include can vary according to the specifics of the animal’s condition and treatment. However, generally records should include, but aren’t limited to:

  • client identification
  • treatment date
  • animal(s) identification
  • history
  • examination details
  • diagnosis
  • treatment options offered and given, prescribed, or supplied
  • informed consent
  • response to treatment
  • other records/reports such as imaging reports, laboratory reports or specialist/referral reports
  • information provided to the client including post treatment instructions

In some cases, it’s worth noting what didn’t occur as well as what did. For example, if a client has refused to consent to what would be considered the most ideal or obvious treatment option, the record should reflect that it was discussed and declined. If it’s simply left out of the record, it would appear that it wasn’t discussed as an option.

When veterinarians are unsure if they have included enough detail, they should ask themselves whether or not another veterinarian could read the record and understand the full picture of what took place and why, without the treating veterinarian filling in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Records need to always be professional and objective. Criticisms of the client can be included, however this must be professional and only when relevant to the treatment being provided. This may occur in situations where the client isn’t complying with instructions and this is detrimental to the health of their animal. However, it’s important to remember that records can be accessed and read by a number of people, including the client and your regulator, so always be mindful of the language used. The language used should match the professional language a veterinarian would use when speaking to the client during a consultation.

Changes and corrections

If it’s noticed that errors have been made in a record, changes can be made to correct this. However, information should never be deleted. The original information must remain with a note explaining the correction and when the correction was made. Also, if additional information needs to be added to a completed consultation note, it should be done so it’s clear this is additional information and the date it was added.

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