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


For records to be admissible as evidence, they must have been made “at or near the time” of the event they describe.2 The law starts with the presumption that records made while the information is the most fresh are also more truthful and accurate.
Example: Doctor A does not have time to complete patient charts until the end of the week. Doctor B completes patient charts at the end of the day. Doctor C completes patient charts throughout the day, following each examination or procedure. If Doctors A, B, and C all made the exact same record, the law would generally favor Doctor C’s records as the most credible, whereas Doctor A’s records may not even be admissible for the doctor to say what did or did not transpire. As a result, Doctor A’s records of treatment will be open to interpretation to what the client remembers. 


For records to be admissible as evidence before a court and most other tribunals (such as a board of veterinary examiners), they must be regularly and uniformly kept in the ordinary course of business.2
Example: Hospital A is extremely busy with routine spays and neuters. To save time and expense, the hospital does not have an assistant or tech complete anesthesia monitoring records during surgery. Instead, the hospital policy is to record only adverse events, which are extremely uncommon. The result: not only are the records irregularly kept and most likely inadmissible to prove something did or did not happen, if the records were subpoenaed, they would show that all spays and neuters resulted in adverse events because those are the only records that exist.  


Policies and procedures for recordkeeping must also be routinely and uniformly enforced.
Example: A receptionist was terminated for failing to obtain a “Consent for Surgery” form and made a claim for unemployment benefits. The hospital produced a signed training manual as well as a signed policies and procedures manual illustrating surgery consents were to be obtained for any procedure requiring sedation/anesthesia. The hospital also produced the receptionist’s previous history of complying with the policy. The result was a denial in unemployment benefits because the receptionist failed to follow a clear and uniformly enforced policy or procedure.

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