The improvement of medical record documentation in veterinary practices is a clear requirement in the new millennium. The better the standards of care are understood, and the continuity of care is reflected in the written documents, the higher the net income! - T.E. Catanzaro, DVM, MHA, FACHE

Medical records are for professional communications between healthcare providers. They should ensure a continuity of quality care and reflect a practice-specific common standard of care. The problem-oriented medical record (POMR) is a documentation requirement that is here to stay. Some like the S-O-A-P (Subjective - Objective - Assessment - Plan), while others prefer to H-E-A-P their records (History - Exam - Assessment - Plan).

In either case, the clear client concern entered behind the date on the progress notes is the charter for examination and diagnostics, while the assessment is the charter for the treatment plan. Chapter 3, Building The Successful Veterinary Practice: Programs & Procedures, and the VCI® Signature Series Monograph Medical Records for Continuity of Care & Profit explore the medical record from the team system approach, as well as the forms and format aspect. Good medical records are what defeats the lawyers in court!

1.  Medical records are required, for liability protection, as well as continuity of care. In most emerging regulations, the phrase reads something like:
Veterinarians must keep animal patient records for all animals with which they have a client-patient relationship, which justifies the assessment, diagnosis, and treatment administered or prescribed. In addition, such records must be legible, written, printed, or prepared electronically as unalterable documents. Records must be prepared in a manner such that any subsequent evaluation of the same animal patient record would yield comprehensive medical, patient, and veterinarian identifying information.

2.  As veterinary practices have grown from one doctor in a town to multi-doctor and multi-practice environments, veterinary use of medical records has evolved from personal memory jogs (circa 1970s) to an essential element to the continuity of healthcare delivery between providers. We have found that when hospitals and providers become aware of medical record benefits, have established standards of wellness and episodical care, and ensure proper documentation is a consistent effort by every veterinary healthcare provider in the practice, net income increases significantly.

3.  The "forms" must be tailored to the practice and the philosophy of the veterinarians in charge. There is no single standard of "completeness". In a practice of dedicated and trained veterinary healthcare providers, "forms" just support their effort. In a veterinary practice of people just doing their job, "forms" generally replace caring and thought. Therefore, forms and procedures become too detailed and cumbersome.

a.  Forms that go home with clients require the practice logo and phone number. Forms used in-house require neither of these, but do require client and patient names, usually at the bottom of the form.

b.  Head-to-foot printing for medical record forms is preferred, so the provider can turn up the page and keep writing on the back, without undoing the prong, since we prong papers at the top of the page. The attachment of the pages is a personal preference, but must be considered when designing any medical record forms for paper record systems.

c.  We are finally seeing some legally sufficient electronic veterinary medical records. In electronic medical records, templates are often used to increase speed of entry. Regardless of the software system selected, the patient record entries must be unalterable at the close of the day/case.

4.  A relational database in a computer means we can ask something, like the following "three-variable" question, and the computer will give us the answer: "How many cases of otitis externa have we seen in the past seven months, which drug(s) were used in the treatment of each case, and what was the return rate per treatment modality?"

a.  We have not found a single veterinary software system that can do this with a single entry source data program. Most veterinary software has not developed a single entry system from the progress notes that will drive the medical records, and worse, most veterinary software systems are alterable, and, therefore, not legally sufficient.

b.  In the developing the existing veterinary software systems, it often appears that the programmers have used simplistic cash register programs, integrated them with word processing and mail merge programs, then added bells and whistles to confuse the consumer. Looking at comparable systems in lateral healthcare fields, experienced information technology (IT) consultants have stated most veterinary systems are worth far less than what the veterinary vendor assesses for procurement, custom tailoring, and/or monthly "maintenance" and update support.

c.  Human healthcare has unalterable software systems driven by mainframes, and specifically tailored to individual facilities. The Mayo Clinic took five years to develop their unalterable software system, and some of their remote clinic sites will not be "up and running" for another three years.

d.  There are "progress note-driven" software systems being developed in veterinary medicine, but they have not been forensically proven yet. Details are in Appendix M of this text.

5.  There are a few other beliefs we need to share with the reader, and most of these are based on the fifteen hundred-plus hospitals we have visited during the past few years. They are based on a strong personal belief in a veterinary healthcare delivery team, rather than just a primary provider, so please accept our bias. Building The Successful Veterinary Practice: Leadership Tools provides most of the key team-building principles.
We usually call these type "reality check" observations the facts of life:

a.  We have visited practices with a ninety-plus percent compliance (documented status) to full preventative services at first visit, and a few with below fifty percent documented status. Some practices have had a current vaccination status within five percent of the initial visit vaccination status, yet when both numbers hover between fifty and sixty-five percent, there is still a systemic problem.

b.  The "pets over twenty-four months since seen" are most often those from single-visit clients, often for grooming, bathing, or boarding contacts, or multi-pet households, where the health status of other pets was not recorded, when one pet of the family was presented for care. The only practices where this is not a problem are those that have a true patient advocate approach and know the status within seventy-two hours of the vaccination expiration date, using telephone contact, medical record documentation, and computer entries, which are supplemental.

c.  While some medical record data reflects "violations" of internal policy or quality patient care, it is more often attributed to failures in the documentation process. These types of "failures" in documentation often lead to internal control problems, liability/forensic concerns, embarrassment to the practice or client, or a reduced value per pet seen. The bottom line is that these trends reduce the continuity of care value of the medical records as well as the liquidity of the practice. Review continued quality improvement (CQI), which has been discussed frequently in the chapters of this text

d.  When we hear a receptionist say, "That part of the medical record is not my concern," we know there is a systemic problem. Any divided POMR system is a perfect example of inefficiency looking for a place to destroy the continuity of care. Most practices need to consolidate the medical record review and retrieval responsibilities under the lead receptionist, but any five-by-seven note card systems require re-evaluation.

e.  The world of veterinary healthcare is going to the standard medical record folder, when using paper records. With hanging pocket systems, such as ANCOM, profiles, etc., or terminal-digit medical record file folders on open shelves, space limitations appear mediated enough to make this alternative a viable option. High-density file systems are available.

f.  The "habit" of a doctor or technician needing to keep a medical record after the animal has left the facility is outmoded, ineffective, and very discourteous to others. Medical records maintained at the reception area can be found by everyone, whether it be for filing lab results, pathology reports, or answering questions, when the client calls back.

g.  The medical record belongs to the hospital, not the provider, and, when not with the animal, it must be in file. The receptionist needs the unilateral authority to retrieve and file any "lost" record at any time, and the doctor who "was working on it" needs to apologize to the team rather than berate an individual.

h.  The value of good medical records can be seen with better continuity of care for patients, but also has a litigation protection value. Legal concerns seen during frequent medical record audits, from one hundred records from a single practice, done in over three hundred different practices, included:

i.  No client complaint (reason for access).

ii.  No dental status/weight/TAR in multiple visit pets.

iii.  No admission action noted for inpatients.

iv.  Lack of pre-surgical assessments.

v.  Surgery without a reason for surgery being noted in the medical record.

vi.  Tumor surgery, without client permission, being recorded.

vii.  Recurrent cardiac dysfunction patients treated with Lasix with no diagnostics or follow-up recorded.

viii.  Medication prescription without full SIG (dose, frequency, duration, etc.).

ix.  Treatments without reasons.

x.  Inpatient care without vaccination status or client waiver.

xi.  Ambiguous statements, such as "shots current" or "previous seizures", without an approximate date or description.

xii.  No discharge planning, at home or for next visit.

xiii.  Records contradicting themselves, especially with sequential weights, dental status, etc.

xiv.  Problems being ignored in successive patient presentations, or at least by lack of record entries.

6.  Many practices have used Section One of the AAHA Standards for Veterinary Hospitals to align their systems with the state of the art, while the traditionalists are still using inadequate five-by-seven card stock. It is interesting to note, many state boards have adopted a "medical record data requirements" list similar to the AAHA Standards, including:

a.  Complete ID of client (person presenting the animal), including address and phone number

b.  Name, age, species, breed, and color of animal.

c.  Dates and times of examination/treatment, as well as admission custody of the patient.

d.  Medical history information, including all vaccinations.

e.  Presenting complaint.

f.  Physical assessment information. "bar except..." is seldom adequate.

g.  Treatment, as well as intended treatment plan, with attendant prognosis.

h.  Differential diagnosis, and final diagnosis if available.

i.  Surgical procedures, including surgeon ID, summary of procedure, noting any abnormalities or complications, anesthetic/sedative agents with route of administration, strength, and clear identification of agent(s) used.

j.  All medications and treatments prescribed and dispensed, including strength, quantity, and frequency.

k.  All clinical laboratory reports, imaging records, and consultation reports, with assessments of atypical findings.

l.  Consent/authorization forms. AVMA Directory version preferred.

m.  Documentation of all forms of communication, including services declined.

n.  Signed name/initials of veterinarian responsible for the episode's entry.

7.  When a herd, flock, litter, or similar non-specific group is presented, the usual minimal standards include:

a.  Complete ID of client (person presenting the group of animals), including address and phone number.

b.  Species, breed type, or flock identification, and number of animals seen.

c.  Individual animal ID, where individual treatment has been requested and delivered/treated.

d.  Type of call, such as routine vaccine, parasites, emergency, etc

e.  Assessment information, including diagnosis or condition, status and prognosis

f.  Advice and treatment provided.

g.  All medications and prescriptions administered and/or dispensed, including strength, quantity, and frequency per animal.

h.  Number of animals treated and dates

i.  Name of attending veterinarian responsible for the episode.