CHAPTER 11 Protecting Yourself with Medical Records
“Good medical records often get veterinarians out of potential trouble because they document a quality of care that refutes the client’s allegation.”∗ Without legible, accurate, and timely documentation, your medical records may lead to the perception of poor patient care. Veterinarians serving on your Board of Veterinary Medicine (BVM) also perceive gaps in medical records as indicative of substandard practice. In the event of a dispute between you and your client, the same record serves both sides of the issue. Will your documentation best support you or your client’s case? “If it’s not written down, it wasn’t done!” This is how the client, his or her attorney, your professional liability insurance agent, and the BVM will regard your medical records. Veterinarians can be more assured that their medical records are legally defensible by applying the following documentation guidelines.
THE CLIENT’S BILL IS NOT THE PATIENT’S MEDICAL RECORD
What Happened to the Patient While Under Your Care?
Signed, informed consent forms must address the following†: potential benefits and drawbacks of the recomended course of treatment, potential problems related to recuperation, likelihood of success, possible results of doing nothing, significant alternative treatments, and financial responsibilities. If the client waives or defers the recommended care, that must be recorded. Veterinarians often create their own trouble with the client by failing to communicate regularly or procrastinating about the reporting of bad results. The client’s perception of how often you make contact and the nature of the conversation can be refuted only by timely documentation in the medical record. For this reason, a record must be kept of client communications, including documentation of unsuccessful attempts to reach the client. Records of medications, including fluid administration, must include dosage, route, frequency, duration, and when and by whom the medication was administered. There must be an accurate description of anesthesia, preferably on an anesthesia form, including agents, route of administration, duration, identity of the anesthetist, and documentation that the patient was observed at frequent intervals until fully recovered.‡ Consultations with specialists, including the name, date, and recommendations delivered, must also be recorded.
