Thoroughness matters when it comes to case documentation

Over the years as a private practice owner, I have employed dozens of associates. Among them, I have observed an amazing range of record-keeping attentiveness. In some instances, I would come in to manage a patient when a certain doctor had been on call only to discover that I had to virtually begin the work-up from scratch. It's not that this fellow had not been thorough; rather he just left me with haphazard, incomplete documentation that left little in the way of a trail to follow.

On the other hand, I had one young veterinarian who worked for me whose verbiage and attention to completeness was so extensive that technicians and receptionists used to tease her about it. They sometimes used to refer to her medical records as a novel.

My recommendation to you, speaking as a veterinary lawyer, is that while you may not want to write a novel, you at least should try to write a well-researched investigative report. The report needs to be complete in two regards: One, it should completely document the medical case in order to best help your patient. It must contain all of the necessary information and warnings to protect its author from later having to answer to a court licensing board.

When a medical record is retired for the day, its completeness or lack thereof is permanently set. You aren't allowed to add later thoughts and attribute them to an earlier time. Subsequently, if a problem develops with an animal, your record becomes reality. When your written record is reviewed some time after your examination or your procedure, memories have faded and the time for elaboration has long past.

Put it in writing

I have included a number of expressions that you may find useful to include in any given record before it is retired for the day and becomes potential evidence.

• "Unable to assess/evaluate..." There are many times when a dog or cat is so viscous that you may not want or be able to get close enough to evaluate teeth, CRT or even a genital or rectal tumor. It should be mentioned in the record that you did want to evaluate everything, but the animal's attitude made it impractical or impossible to do so, at least while awake. I have seen veterinarians called to task for missing such things as a tooth abscess that develops shortly after an annual physical exam. The record should explain how any unexamined region got missed.

• "Declined bloodwork/radiographs..." Most veterinarians are aware that it is very important to memorialize an offer to do diagnostics and the decision by the owner to not pursue that course. If you are an experienced practitioner and tend to be cryptic in your records, or you are a young doctor who is just trying to keep her/his head above watering appointments in the allotted time, know this: When an animal dies and an owner previously sought veterinary advice, that owner may well later claim that diagnostics were not suggested. If you don't document the offer, you are vulnerable to the claim.

• "Your dog needs obedience training and even with it, may be a danger to the public..." Every year, a civil litigation against and criminal prosecutions of irresponsible dog owners proliferates as more and more innocent people are unexpectedly attacked.

It is a veterinarian's legal and moral responsibility to let owners know when their dog has had a dangerously aggressive attitude. Telling the owner this probably discharges the moral obligation. However, the legal responsibility is not met until the warning is documented.

• "Advised of risk of feline viruses to other cats in house..." Many of us have had to explain to owners that their prior refusal to test for FeLV/FIV was a proximate cause of their having wasted financial and emotional capital on a cat that died prematurely. What you don't want to have to do is explain why you failed to warn an owner of the danger to their cats from bringing an untested cat into the household. "I always warn them," you say. I say, "If it isn't in the record, you didn't."

• "Advised of guarded prognosis even with IV fluid therapy..." I have dealt with a number of clients of other veterinarians in cases where a dog or a cat died of kidney failure shortly after an expensive source of intravenous fluid therapy. These clients were either distraught, or not listening when their veterinarian initially explained that fluid therapy might not be an adequate to meaningfully extend the renal patient's life. To protect the practitioner legally, it is important that the prognosis be clearly set fourth in the record as well as the explanation to the client that the fluids may not end up being that helpful long term.