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.

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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Pet insurance companies will often ask for clinical record information to assist with processing a claim. In the event that a claim is denied, this information may then be provided to the client as part of the explanation as to why the claim has been denied. This means that the clinical records created, and owned, by the veterinarian can end up in the hands of the client. And this potential outcome has led to some veterinarians feeling reluctant to hand their clinical records over to a pet insurer.

Handing clinical records to an insurer – what are the risks?

When considering handing records to a pet insurer, it’s important that a veterinarian is mindful that the records may be seen by the client. But what does this mean for a veterinarian? Not only is there a chance that records can be seen by a client during a pet insurance claim process, but records can also be seen for other reasons by a State Veterinary Board or a professional indemnity insurer. This is one of the reasons why it’s an expectation that records are always written in an appropriate and professional manner. Comments in the record should always be objective and relate to the treatment provided. Unprofessional comments in the clinical record that are then seen by a client are likely to lead to an unhappy client who may complain about the veterinarian’s conduct.

Some veterinarians may be concerned that another risk of the clinical record being seen by a client is that information contained in the record may lead to a complaint by the client and that the complaint won’t be covered by the veterinarian’s professional indemnity insurer. What is and isn’t covered by a professional indemnity insurance policy is detailed in the policy wording. Unless what is recorded in the clinical record amounts to an admission of liability, or otherwise triggers an exclusion clause in the policy, the fact that a client sees a veterinarian’s clinical record is rarely the basis upon which a claim is denied. If a claim is to be denied by the professional indemnity insurer, it’s generally as a result of other actions of the veterinarian, not the action of sharing the record.

There is a possibility, albeit slim, that the client may read the clinical record and form a conclusion that the veterinarian has acted in a manner which is inappropriate or negligent. However, this possibility shouldn’t be a reason to not share the clinical record. It’s important to remember that you can’t stop a client from complaining if they feel they have a reason to do so; it is their right. However, it’s also important to remember that this is why veterinarians have their professional indemnity insurance, to protect them when a claim is made against them.

Not handing clinical records to an insurer – what are the risks?

While there are some risks to consider when handing clinical records to a pet insurer, veterinarians should also understand that there are risks to consider when they choose to not hand over those records. If a veterinarian opts to not share the clinical record with a pet insurer when a client has made a claim, it’s possible that a claim won’t be processed and the client will not be able to receive the rebate they may otherwise be entitled to. Veterinary care can be considered expensive for many clients. Those who take out pet insurance are choosing to buy insurance to attempt to assist with veterinary costs. For them to not be able to make use of that pet insurance would mean they’re paying full costs for the treatment as well as an insurance premium that isn’t being utilised. This occurring may well upset and frustrate the client, and it is often the frustrated clients who are more likely to complain.

A veterinarian also needs to consider the importance of maintaining clients to keep their business running successfully. A situation where one veterinarian refuses to share clinical records with pet insurers, yet another veterinarian does share them, could lead clients choosing their veterinarian based on who will support their pet insurance claims.

Don’t forget…

• Sharing information within a clinical record is not usually the reason for a professional indemnity claim being denied.
• Always keep detailed, accurate and up-to-date records of all clinical consultations and treatment.
• The information contained within a clinical record should always be professional and objective.
• Whilst the veterinarian is the owner of the clinical record, be sure you have the client’s permission prior to sharing the record with a pet insurer.
• If there is any situation that a veterinarian thinks could lead to a claim against them, they should notify Guild Insurance immediately by calling 1800 810 213.

Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791. This article contains information of a general nature only, and is not intended to constitute the provision of legal advice. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them.

All health practitioners would be well aware of their requirements to obtain informed consent from their patients before assessment or treatment takes place.  However, Guild Insurance’s vast experience in managing claims made against health practitioners has highlighted that many practitioners don’t meet all their informed consent requirements.

What is informed consent?

There is an explanation about informed consent in the Code of Conduct for each of the professions regulated by AHPRA.  In this document, informed consent is defined as ‘a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved’.  This statement highlights the difference between consent and informed consent.  If a patient hasn’t been made aware of the benefits and risks, their consent isn’t informed.

Informed consent isn’t just required for treatment. Depending on the nature of the healthcare being provided, informed consent should also be obtained for assessment. 

Informed consent and insurance claims

Informed consent can feature in insurance claims against practitioners in a couple of ways.

It’s not uncommon when a patient is unhappy following treatment for them to allege they weren’t made aware of the risks when they consented to treatment.  Quite often they will allege the treatment was negligent and has resulted in harm or suffering.  They then add that had they been informed of the possible risks, they wouldn’t have consented.

In other cases, patients may not make any allegation about consent, their complaint might solely focus on the clinical outcome, yet when their claim is being managed it’s found that they didn’t give their informed consent prior to treatment being provided.  When this occurs, it makes it challenging for Guild to prove that the practitioner has treated appropriately and met their requirements.

The informed consent conversation

Informed consent requires a conversation between the treating practitioner and the patient.  This conversation needs to occur prior to assessment and treatment. 

The conversation must:

• detail the recommended assessment and treatment as well as alternate treatment options
• include the expected benefits of that treatment
• provide information about the risks of the treatment
• allow time for the patient to ask questions
• be held in language which can be understood by the patient which means practitioners should avoid technical clinical language.
• take place in a private area where the patient will feel comfortable being open and honest about their health situation.
• be tailored to that individual patient and their unique clinical needs

Recording informed consent

It’s imperative that practitioners make a note in the clinical record regarding the patient providing their informed consent.  This needs to be more than ‘IC given’.  The record needs to show what treatment options and risks were discussed as well as any questions asked by the patient.  The record should also show what the patient consented to as well as what they didn’t consent to where relevant.

The informed consent form

One area which leads to some confusion about informed consent is how to use an informed consent form.  Having a patient sign a form is seen as a quick and simplified way of having a patient provide their informed consent and keeping a record of that.  However, they are unfortunately too often used inappropriately. 

Signed forms aren’t a requirement.  While recording consent is required, this doesn’t need to be done using a form.  Notes in the clinical record are sufficient.  However, signed forms do provide additional evidence if there is an allegation that informed consent wasn’t given.

Forms can’t be used to replace the informed consent conversation.  A patient can not read a form and gain the same level of understanding as they would from a conversation with the practitioner.  Nor can they ask questions of the form. 

A form should only be signed after the conversation with the practitioner has been had and the patient understands what it is they’re consenting to.  Patients are occasionally asked to sign consent forms at reception before they’ve seen the practitioner.  As there has been no assessment or discussion about treatment at this stage, this can’t be considered informed consent as the patient hasn’t been informed.

Some practices combine new patient forms with the consent form.  This isn’t ideal as the two forms serve different purposes.  Also, having them on the one form encourages patients to sign the consent form at reception before they’ve seen the practitioner.  Therefore, they should be divided into two separate forms.

Informed consent is not a one-off event

Practitioners regularly ask how often their patients need to give informed consent.  There is no set time frame for when informed consent conversations or signed forms need to be repeated.  The requirement is that when a patient is receiving any assessment or treatment, they need to have given their informed consent to this.  Therefore, informed consent should be an ongoing process; it’s a continual conversation with patients during consultations.  And when there is any change in the treatment being provided, or if the patient has returned following a period of absence, informed consent needs to be revisited.  A general ‘consent to all treatment’ for the life of the therapeutic relationship is not appropriate.

Informed financial consent

As well as consenting to assessment and treatment, patients should also give their informed financial consent.  This means they need to be provided with information about the expected cost of treatment before this treatment commences.

In summary…

There is no one right way to undertake an informed consent conversation and process.  Practitioners must adapt what’s discussed for the patient they’re treating and that patient’s unique circumstances.  However, what must occur in all cases is that the patient is informed of and understands the proposed treatment, alternate treatment options and the risks involved.  Only with this information can they give their informed consent.  The practitioner must also be sure to make a record of this informed consent discussion in the clinical record.

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