August 02, 2016

Preventive Legal Health: Legal Risks of Bad Veterinary Recordkeeping

In veterinary practice, proper recordkeeping must be kept in order to prevent legal risks and repercussions.
By Anthony A. Mahan, Esq, MBA
The veterinary industry is ingrained with the concept of preventive care as the best method to provide quality healthcare for patients. The approach of preventive care, however, applies to the entire veterinary practice and not just patient health—a term I refer to as “preventive legal health.” Preventive legal health is using legal best practices to keep your business free from illness or injury. Much like the vet who only sees a patient when sick, my firm is often called to the veterinary practice as a necessary evil to deal with a problem that could have been resolved with routine preventive measures. At the forefront of best practices for preventive legal health is proper recordkeeping.
To veterinarians, “records” are most often associated with patient charts, but can include any record utilized in the business, such as human resource documents, policies and procedures, client and patient notes, invoices and statements, inventory, controlled substance logs, surgery and anesthesia logs, radiographs, etc. To attorneys, business records inevitably become synonymous with “evidence” used to prove something did or did not transpire. The lack of evidence leaves a situation open to interpretation as to what truly transpired—for this reason, attorneys are ingrained with the principle, “If it is not in the record, it did not happen.” In veterinary practice, proper recordkeeping is a must and should follow the guidelines listed below. (“Real-world” examples have been included after each guideline to aid in proper understanding.) 


Records should be written in a manner such that a relief veterinarian could open the patient chart and be brought up to speed. Notes made in cryptic shorthand should be avoided. If shorthand is routinely used in your practice, a written abbreviation chart, which includes both well-known and lesser-known abbreviations, needs to be a part of your office policies and procedures. In addition, complete and meaningful recordkeeping involves using consents and waivers (see below) to ensure that proper informed consent and recommendations have been given and recorded.
Example: Doctor A works in a fast-paced practice. To keep up with appointment times and scheduling, Doctor A uses the following objective shorthand for record-keeping following an appointment: PE: LE, M, BAR, BCS 6/9, sore abdomen, DECL HWT RADS. Although most veterinarians are knowledgeable about many abbreviations (ie, Physical Exam [PE], Bright/Alert/Responsive [BAR], Body Condition Score [BSC]), they might not have picked up on “Limited Exam” (LE) or “muzzled” (M), which could result in physical injuries to the next doctor if the animal was muzzled because it posed a danger to the first doctor. Best practices would be to use your database software to create alerts for dangerous pets and to incorporate modifiable, routine notes so that they are meaningful to anyone reading the chart. Records must generally be “adequate and sufficient” pursuant to most
veterinarian codes of conduct.1
Additionally, although recording a doctor’s notes regarding declined recommendations, such as heartworm tests or radiographs, by using “DECL HWT RADS” is better than nothing; best practices dictate that the client sign an “Against Medical Advice” form or “Waiver” to record that they have provided informed consent of not following medical recommendations. Remember: If it is not in the record, it did not happen.  

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