10 key rules for record keeping

By James E. Guenther, DVM, MBA, CVPM

Your top priority is to give pets the care they need, right? So one of the first questions to ask yourself is, does your record-keeping system reflect your practice’s standards of care?

Ideally, your records give you precise, accurate information about your patients. And your record-keeping system must be logical and organized so your team members get that information on every case quickly and easily. For example, a record should give you easy access to information about your past observations, treatment protocols, and interpretations of lab tests or radiographs. And as the practice leader, it’s your job to help your team capture the wealth of information available and use it to provide better care.

I like to think of it this way: The medical record is your patient in written form. So you need to treat the record with the same care and compassion you would offer the pet.

Of course, record keeping is a legal issue as well as a healthcare issue. Your records will be your best ally—or your worst enemy—if a client takes you to court. The truth is, malpractice suits can be won or lost based on what’s noted—or not noted—in a medical record. And while a small error or incorrect notation may seem minor to you, it may be the difference between winning and losing in court.

To avoid small errors—and big oversights—that can land you in legal hot water, I recommend that you follow these 10 key rules of record keeping:

No. 1.

All entries should be neat, legible, in ink, and signed or initialed. Here are the “whys”: The guidelines for AAHA hospital certification specify that all records must be easily read and understood by any veterinarian. Notes made with ink are harder to alter, which gives them greater credibility. And you need to sign or initial notes to show who did the work and that it was indeed done.

No. 2.

Record entries in chronological order and note the date and time. This approach lets the doctor, technician, or other parties easily trace the patient’s history.

No. 3.

Entries shouldn’t reflect future care or intentions unless you feel sure you’ll perform the service. For example, if you make a note in the record to recheck in five days, you either need to perform the recheck and document it, or you must note that you didn’t perform the care and explain why not. Without such documentation you could take tough questions from a lawyer about why you didn’t continue the care you suggested in the record.

To help you keep up with recommendations, ask a technician to call the client within 48 to 72 hours of your recommendation to check in. Your technician will then make a note about the client’s response in the record and let you know whether you need to see the pet again.

No. 4.

Entries must be accurate, objective, and concise. You don’t need to write a novel about each case, but you do need records with substance. The challenge: cover your findings or treatment without being wordy. Writing only “fix hernia” leaves a lot to the reader’s imagination and opens you to a multitude of questions from fellow doctors or attorneys. The key to keeping it short is to stick to the facts. But make sure you give all the facts any veterinarian would need to understand the situation completely.

No. 5.

Enter only what you clearly understand and can interpret with confidence. Don’t assume anything. So when you look at a radiograph and see a metallic, round object—say so. Don’t say “it’s a funny shadow.” What makes it funny? Be precise.

No. 6.

Use only standard abbreviations. One of your biggest complaints is likely that writing complete records takes too long. Help yourself out by using AAHA’s approved abbreviations. And make sure you teach your team members these terms. If you don’t, it may be a costly experience. For example, if your staff members don’t know that BID means “twice a day,” they may not provide the appropriate medication.

No. 7.

Write each entry as if the client or her lawyer will scrutinize it. After all, you never know who will read your records. Keep in mind, in the eyes of the court, if you didn’t write it down, you didn’t provide the care.

No. 8.

Correct any errors by placing one line through the incorrect word(s), make the correct entry, then sign and date the change. Never use correction fluid or blacken out an entry. The issue here: You don’t want to cover part of the entry, because that could signal that you’re hiding something. A single line through the word or phrase makes it clear that you didn’t conceal anything about the care you offered.

Lest you think I’m over emphasizing this point, I know of a case that a practice lost because the prosecution argued that a covered-over line in the record showed the practice was hiding something. The transcriber actually typed one line twice and merely corrected the mistake.

No. 9.

Don’t make entries in the margins or between lines. Margin notes can be distracting and may be interpreted as a comment made later, or an alteration to the record. If you must add information, note the paragraph you want to add to, make the comments later in the record, then sign and date the addition. It’s better to be open about the change than to let someone believe you altered the record because of the threat of a lawsuit.

No. 10.

Never make any derogatory statements regarding a patient, client, or another veterinarian in the medical record. And never make negative comments about equipment or personnel that may have led to a less-than-adequate outcome. Why give an attorney an opportunity to assume you offered a lower standard of care? Of course, if you know you’ve done something wrong, communicate the problem openly. Honest, compassionate communication of the facts in the record and with the client is your best response.

As a consultant, veterinarian, and former hospital administrator, I can tell you that good medical records are a must. Yes, they’re a pain to write up, store, and update, but they provide a wealth of information that can improve practice effectiveness and efficiency.