LEGIBILITY OF MEDICAL RECORDS

Records must be legible and able to be read by anyone. Many team members become proficient at being able to read records written by another team member, but once those records are released to another clinic, specialty hospital, or court, the intended audience may not be able to read them. This can render a record incomplete. If a record was sent to court, a judge may return a decision based on the opinion that a treatment did not occur because he or she could not read the record. A veterinary specialist may not be able to determine if a specific treatment was done since it was not legible. An incomplete, illegible record can be considered an admission of professional incompetence and imply that the service provided was substandard. If records are illegible, changing to paperless records can be a good idea.

If legibility is problem within a veterinary practice, the use of labels or stamps may be suggested for routine procedures. Physical exams, urinalyses, routine dentals, and alterations are just a few labels that can be generated in a fill-in-the-blank form to accommodate details. Size of suture material can be easily added on surgical stickers, normal findings can be easily marked on physical exam stickers, and abnormal findings can be clearly defined below the label or stamp (Figure 14-2).

Blank labels can be purchased at a local office supply store relatively inexpensively. A label can be created within Microsoft Publisher and can be changed at any time to fit the needs of the practice.

A medical record is a legal document. Correction fluid cannot be used on any medical record, release, or authorization form at any time. If a mistake needs to be corrected, a one-line strike-through can be written, with the author’s initials indicating the correction (Box 14-1).

CHOOSING A FILE SYSTEM

Practices that use paper records may file records according to different methods. One method is to file alphabetically. All records are filed by the owner’s last name, then the first name. Other practices may file by client number. All pets are kept in the same file because many owners have more than one pet. Also included is a client/patient form (see Figure 2-8, A; Client Patient Information Sheet). Consent forms, patient check-in sheets, discharge sheets, and any other forms must be kept in this file as well.

PAPER RECORDS

Paper records can either be classified as full paper records or index card records. Paper records are written on 8.5 × 11-inch paper and usually fastened into a file folder with a two-hole fastener (Figure 14-3).

All lab work results, invoices, consent forms, and miscellaneous documents are kept in this folder. Pets can be separated by colored paper. Some clinics may use either blue or pink paper to draw attention to the sex of the patient. Names can be listed on the colored paper with tabs for quick access. The medical record may also be either blue or pink, indicating the sex of the patient. Some practices maintain one file per pet even when they come from the same household.

Index card files are usually kept in plastic holders and filed by the client’s last name. Medical records are written on 5 × 8-inch index cards. All forms, charts, and lab work results are stored in the plastic holder.

Clinics that use full paper records generally have more complete records than those that use index cards. It is not unusual for a sick patient to have one full page of history on a full paper record, whereas those with index cards will have only a few words. Team members seem to write less on index cards. State board investigators do not recommend index card records for this reason; records are often incomplete and illegible.

Either file folders or index card holders can be alphabetized by client name or filed by client number, and colored letters and/or numbered labels can help identify those that are misfiled (Figure 14-4). Color coding the exterior of files can help identify misfiled charts from either the front or the back. Numbers indicating the year on the outside of the file can also help identify the last time a client has been into the practice, making it easier for team members to purge files efficiently. Alphabetical filing is the most common method used in practice. The last name, then first, along with a client identification number, are generally listed on the exterior of a file; the file is then alphabetized by the client’s last name.

Colored warning stickers attached to patient medical records may draw attention to special medical needs. Sample stickers may include: “Will Bite!” “Anesthetic Alert!” or “Vaccine Reaction!” Figure 14-5 shows a variety if stickers that a practice may use in a paper record system. Bright-colored stickers can also be used on cage identification cards to alert team members of a patient’s special needs. A “Will Bite” sticker is beneficial for alerting team members to animals with which they must use special precautions.

Although patient medical alerts should be obvious, team members can get busy and overlook a handwritten alert. A sticker that is big, bright, and bold will catch the attention of staff members. This is a cheap method for preventing a potential disaster.

COMPUTERIZED MEDICAL RECORDS

Computerized medical records, also referred to as paperless records, are filed in the computer by both client number and last name (Figure 14-6). Any record can be accessed from any computer. Lab work, radiographs, and ultrasound results are stored within the record. All charts, consent forms, and miscellaneous documents must be stored within the record. A practice that is truly paperless does not have any additional client files or folders that store release forms, lab work, or radiographs. Forms and lab work are scanned into the client’s record, or the client must sign the forms electronically, which are then stored in the computer. Radiographs are either in digital form or they are scanned into the record. Most lab work machines will enter results into the client’s file once the machine has completed the work. Client identification numbers must be verified before entering lab work to ensure the results will be populated into the correct records. When outside laboratory results are received, they can be electronically filed within the patient’s chart. An onscreen notice pops up for the veterinarian or staff when those results have become available.

Computer medical records must be secure, with access limited to authorized individuals only. Computers must be backed up daily and monthly, preferably off site for the best security. Software should have an automatic lockout time period, preventing records from being changed after a backup has been completed. Late entries can be added, but a new date will appear with the updates.

Patient information can be added to computerized records in several ways. Doctors may enter information while they are examining the patient, a veterinary technician or transcriptionist can enter notes written by the doctor to complete the record, or a doctor may use a template that has been generated by the computer to compete the record.

Paper records and paperless records each have their advantages and disadvantages, all of which must be weighed when determining what is best for an individual practice (Box 14-2).

The greatest advantage of paperless records is being able to access them from any computer. Most paperless practices have a computer available in every exam room, office, and laboratory area. Records are never lost, misplaced, or misfiled. However, computer systems can fail; therefore records may be inaccessible until the system has been repaired. A “plan B” should be developed in case a system does crash to prevent a major catastrophe from occurring. This may include having a few laptops that serve as backups if a computer becomes unusable. The laptops should have software preloaded, allowing them to be plugged into the server and available for use immediately. If the main server becomes unusable, a second unit should be available, and the CD with data from the last daily backup can be loaded. This will keep the practice flowing until the main server has been repaired.

A major disadvantage of computerized medical records is the lack of security to prevent alteration. If a record can be altered, it may be questioned in a court of law. The practice attorney should be consulted regarding the likelihood of problems if a malpractice claim arises. Backing up information onto CDs that can only be written on once may satisfy the court.

Some software companies are excellent at providing medical record lockout periods; these lockout periods prevent medical record alteration after 24 hours. Others do not have a lockout period, allowing records to be altered days, or even months, later. This disadvantage must be considered when choosing software for the practice.

The advantages and disadvantages of computerized software change annually as new technology is introduced. Computers and software initially can be costly, but the efficiency they make possible far outweighs the cost. Updates are made available for current software users and should be used to maximum potential.

CHOOSING MEDICAL RECORD SOFTWARE

Veterinary software can have a variety of applications. Some software may be management based, helping maintain inventory and create client invoices, whereas other software may be based on medical record management. Some companies have tried to integrate the two; however, computer-generated records are not as flexible as paper records.

Many practices use a combination of both computerized and paper medical records. The computerized medical records can efficiently generate reminders, patient/client alerts, and invoices. Once the patient has been established in the computer system, a paper record is generated for the medical portion of the record. The invoicing system generates a patient history (assuming every procedure was charged for) but lacks the medical details needed to complete a medical record.

Efficiency of Computerized Laboratory Requisition Forms

Some laboratories work with veterinary practices to generate requisition forms online, creating a unique form and barcode. For example, IDEXX (Westbrook, Maine) LabREXX software (www.idexx.com/labrexx) works with existing veterinary practice software, allowing charges to be captured while ensuring no mistakes are made when submitting the client and patient name and doctor. To help increase efficiency, a quick guide of the most common tests the practice selects is available, allowing results to be emailed directly to clients and results to be downloaded to patient records. This prevents lost and/or misfiled results. Records are flagged, allowing the team to know that results have arrived in a patient’s file.

Chapter 8 gives a brief overview of software that is available in today’s market, along with a worksheet to help determine which software will work best for a veterinary practice.

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1. Veterinary Ethics and Legal Issues
2. Controlled Substances
3. Outside Diagnostic Laboratory Services
4. Technology in the Office

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