Writing the right veterinary records

Jim and Karen Warner loved their golden retriever, Skippy. They bought him soon after they were married, and he quickly became a member of the family. Dr. Ware was their family veterinarian and managed Skippy's care for the first seven years of his life. Unfortunately Jim and Karen began to experience marital issues stemming from Jim drinking too much and using illegal drugs, and they eventually decided to file for divorce. Although the marriage was rocky, their commitment to Skippy remained rock solid.

Skippy was a frequent patient at the veterinary clinic, and in most cases, Jim accompanied Skippy for his appointments. He was an active dog and loved to chew on things that were off-limits. Dr. Ware once removed a golf ball from Skippy's stomach, and on another occasion, nursed him through liver complications secondary to ingestion of a toxic substance.

Dr. Ware kept meticulous veterinary records. He believed detailed records were an essential component of responsible pet care and that all relevant observations needed to be recorded in the patient record. During one visit, he noted that Jim was highly agitated; Dr. Ware was concerned about the pet owner's ability to administer a complex medication regimen he created to treat Skippy's chronic disease. Jim commented that it was "too much damn medicine" to give each day. During an after-hours visit in which Skippy was diagnosed with a sprained right rear leg, Dr. Ware wrote down that Jim was somewhat unsteady; he asked Jim if he needed any assistance getting Skippy home safely.

Soon, the Warners' divorce proceedings got contentious. They did not care much about their house, but they did care about who got custody of Skippy. Karen claimed that her husband was a drunk and a drug abuser; she did not think he was qualified to be the competent caretaker of an animal that had a chronic disease. In order to bolster her case, she requested Skippy's patient records, in which Dr. Ware had commented several times on Jim's incapacities.

Jim countered by saying that the use of the information contained in Skippy's records violated his privacy. He understood that most of the information in these records was not privileged, but he believed things like his address and social security number should have been protected. In addition, he held that a layperson's (Dr. Ware's) observations regarding his human condition were irrelevant and should be redacted from the medical records.

Dr. Ware responded to Jim that he had no problem releasing Skippy's medical records to Karen—after all, the two are co-owners. Also, he didn't think it was appropriate to alter any of the information included because in his veterinary opinion, they were reasonable entries that were part of the complete medical record. If Jim had wanted any of the information in Skippy's medical records shielded, he could have certainly asked the court or his representation to do this; Dr. Ware did not feel it was his responsibility to deal with privacy issues in this case. Jim understood, but he was still upset that personal notes about his behavior appeared in his pet's medical history. Dr. Ware continued to hold that his notes and observations were all relevant because they concerned the health and well-being of his patient. A veterinarian must determine if an owner is able to comply with treatment regimens or if he or she is a threat to the patient.

In the end, Dr. Ware and Jim agreed to disagree. Jim said he felt betrayed, and if he obtained custody of Skippy, they would not return to Dr. Ware or that veterinary clinic.

Rosenberg's response

The value of a well-written, complete medical record is immeasurable. It is a pet's link to the necessary care that pet owners must provide. Comments about a pet owner are relevant and should be inserted in the record when these observations impact the health and treatment of the pet.

On the other hand, comments of an emotional or editorial nature have no place in the medical record. Noting that the client was rude or wore a matching outfit with his or her pet isn't pertinent. Keep in mind that taking too many liberties with medical record entries can lead to unwanted repercussions.

Clients have the right to see or procure their pets' medical notes upon request. Unprofessional and even slanderous commentary can be actionable if the client chooses to pursue the issue. In this day and age, when all written notes can potentially be shared with the world with the click of a mouse, it is important to always act in an ethical and professional manner when recording your findings about pet patients.

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Dr. Marc Rosenberg is director of the Voorhees Veterinary Center in Voorhees, N.J. He is a member of the New Jersey Board of Veterinary Medical Examiners.