6 keys to setting gold standard in medical records

Nothing seems simple these days, especially when it comes to maintaining quality medical records.

I am convinced poor medical records cause the greatest stress for a veterinary practice team.

When it comes to formulating a functional system, there are six key issues to address, including:

• Productivity

• Real-time entries

• Accountability

• Audit accessibility

• Duplication and overlap

• Notation quality

Remember that silence can be golden. In other words, if a practice can run silently for an entire day and accomplish all the duties needed, you have achieved the gold standard in record keeping.

My key message: Quality medical records are essential to deliver quality medicine.

Let us examine the six central issues for private practices:

Productivity

The use of personnel to provide comprehensive care for veterinary patients is essential. In general, 10 support employees per veterinarian are needed to generate the $1 million benchmark. (This number needs to be adjusted per locale and niche.)

Following the daily (or twice-daily) rounds, a SOAP medical record (Subjective, Objective, Assessment Plan) needs to be created for each patient. Within this SOAP system, the entire plan must be entered into the record for the staff to provide service(s). Note the plan is much more detailed than treatment-sheet notations.

Once the plan is created, the appropriate hospital staffers will look to the medical record to identify their tasks and initial completion of these tasks.

Legibility and the uniform use of templates are essential to productivity. If one cannot read a record and the team is huddled in a conference just to decipher the notation, productivity stops.

Real-time entries

Real-time records are needed for a busy veterinary practice. Entries should be made in the medical record as events are taking place. Specifically, once a veterinarian SOAPs the record, it triggers action within the hospital by the health-care team. A plan is set, and the hospital's staff provides the non-veterinary-administered service: a walk, a pill, a bath, a radiograph or review of individualized home-care instructions.

As services are provided, the appropriate person initials the medical record. Even a 10-minute lag time is unacceptable. Why?

Real-time reporting needs mandates so that other members of the staff, also attending to patients, don't double up on a chore. This could be a disaster.

Further, when a client calls at 10 a.m., support personnel can access the medical records to provide the current SOAP and the status of the current day's events, without interrupting the veterinary nursing staff while they are busy performing their job functions.

(And, maintaining medical records in real-time prevents the inevitable – a stack of unfinished records piling up each hour.)

Accountability

A hospitalized patient could have 20 to 40 separate tasks performed each day.

So, an essential component to recreating the day is to know who performed the function and when. These notations need to be entered into the medical record as an assignment is performed.

Who set up the fluids? What fluids were given? Who took the radiographs? Who drew the blood? Who talked to the family and at what time? When was this patient fed? Was the food consumed?

Accountability is essential to determine that duties were performed. A well-run practice needs this information for operation controls.

Financially, with a Cost-of-Labor-based fee schedule, each duty carries with it a time commitment. Each of these time blocks must fit into the fee schedule. Moreover, these time commitments are needed when planning staff assignments.

Audit accessibility

Mistakes must be contained. Mistakes can be a killer, literally. In human hospitals, 100,000 people die each year simply because of mistakes. In other words, more people die each year from personnel blunders than from either breast cancer or prostate cancer.

Veterinary practices that conduct a daily audit of records data and tasks performed have found a minimum disruption of care (about 10 percent).

All hard-copy veterinary systems can be set up to do these audit chores conveniently.

Auditing electronic medical records is more difficult. But when one person is assigned to audit all the daily real-time entries, the practice operates much more smoothly.

And when another person is set up to audit all of yesterday's activities, patterns of errors are identified and policies can be adopted to fine-tune the system.

It will offer an important internal tool to assess the level of medical care offered to the community.

Was the differential adequate for the vomiting 6-year-old Labrador retriever? How was that cancer patient managed? What chemotherapy protocols were discussed with the owner? What options were given for this patient?

An audit of these evidence-based decisions is essential to consistently practice and deliver quality medical care.

Practice owners who adopt this kind of system find the expense of the auditing team is refunded each day in many ways.

Duplication and overlap

Each time entries are duplicated and transferred, data are lost. Expect a 10 percent error rate. (Ouch!)

The reality: Mistakes happen. And they occur with greater frequency when transferring data from treatment boards to medical records, and vice versa.

If you start comparing medical records to travel sheets, more mistakes are found.

The basic way to prevent these errors is to place medical directives into the medical record, as previously discussed.

Once duties are performed and notations made, fees for services are coming directly from the medical record. Period.

It makes the audit much easier as well.

Notes and such entries

Each time a client calls, each time two veterinarians discuss a case, each change in a patient's condition is noticed, and each medication dispensed – all require critical notations in the medical record.

The same rules should apply for each clinical observation, e-mail correspondence, prescription refill or telephone call to a client.

By addressing each of these issues in medical record keeping, stresses will be eliminated from the administration of the practice's patient care.

Michael H. Riegger DVM, Dipl. ABVP

But the best reason for maintaining the gold standard is excellence in medical care.

Dr. Riegger, dipl. ABVP, is the chief medical officer at Northwest Animal Clinic Hospital and Specialty Practice. Contact him at telephone and fax (505) 898-0407, Riegger@aol.comor www.northwestanimalclinic.com. Find him on AVMA's NOAH as the practice management moderator. Order his books "Management for Results" and "More Management for Results" by calling (505) 898-1491.