Good Medicine, good business

Maintaining quality medical records is obviously an important part of delivering high-quality healthcare.

This column will review the many components that go into creating a dynamic and active medical record.

Table 1. Star of the Medical Record

Table 1 is a representation of how activities can flow from the medical record.

Here are some important considerations when it comes to using medical records to initiate critical hospital functions.

Clinicians need to make entries to activate all other actions within the hospital.

Invoicing can be accomplished by support staff, which allows the veterinarian to move on to the next patient.

Other key business tasks can be accomplished directly from the medical record while the veterinarian moves on to the next patient.

Infrastructure, including duties associated with patient care can be taken directly from the clinician's entry in the medical record to allow veterinarians to see new patients.

Patient Care Auditing is a critically important task completed at least once or twice a day for inpatients and once a day for outpatients. This step can be accomplished directly from the medical record to assure that the clinicians requests are fulfilled.

Accountability, readability, consistency and continuity

• Accountability is an absolute. Mechanisms must be present to assure that controlled drugs are entered into the logs, and that the medications were actually given, not just requested. Each and every communication with a client can be entered into the medical record.

• Readability of the medical record is obviously of critical importance. While handwriting for many doctors could be addressed, the format of the medical record can be made nice and pleasing to the eye to help decipher the record.

• Consistency and continuity are essential components for a well-organized medical record. Formatting for daily clinical assessment, templates for examinations, differentials and in-house patterns for invoicing is central to quality patient care.

A key to productivity is creating a dynamic medical record. One way to assess the medical record is by looking at the thoroughness of the treatment board, as well as the notations by the entire staff about each patient's status without individuals interrupting each other.

Make it a living document

A dynamic living record essentially provides the central element of "Good medicine is good business" in that the record contains the history, the current clinical status, the current plan and the planned path.

Detailed homecare instructions must be part of the record so the entire staff can assess follow-up care. It also should be used as a resource when a client calls the clinic to affirm homecare directives or to double-check pharmacy items.

Auditing the medical record for completeness is also a big issue. Having a clinician review 10 percent of the medical record entries can help identify patterns of behavior that might be either nurtured or modified. This type of audit also can identify critical issues of completeness, and it offers the opportunity to apply business-management ratios, such as the Diagnostics Ratio (gross revenues divided by diagnostic revenues).

Creating a master problem list is an expectation, yet it can be given more attention and use by the clinician.

Preventive healthcare lists and recorded patterns of recommendations can smooth over conversations that the client begins, "You never told me ... ." Furthermore, it is only with the daily, monthly and continual presentation of recommended preventive healthcare in a nice smooth non-pressured manner that enjoys an informed client base.

Marketing sensitivity to the use of tickler files and recall systems can be generated starting with the medical record entries. Tuned recalls, or perhaps better stated as individualized recalls, are a central issue for quality medicine as individuals with complex medical issues need titrated recall activity.

Rabies ratios and rabies ratio targets monitoring can be accomplished within the auditing of the medical record. These two ratios help identify missing endocrine patients, ophthalmic dry eye and growth patterns of diagnostic skills.

Computer activities are out of the loop as in most veterinary practices; the computer is primarily an invoicing system. But keep in mind that many quality systems are available to help streamline this process.

Releases signed and estimates documented are last on the list, but it should not to minimized.

My personal Perfection in Medical Records Award goes to the medical record system where there is no travel sheet for the veterinarian.