Veterinary Medical Records

Record Keeping

Accurate and complete records are essential in small animal veterinary practice.

What Needs to Be Recorded?

Veterinary medical records include forms, documents, and logs which record the treatment and care of animal patients. These are dynamic documents that record the sequence of events each time the veterinarian sees or communicates with that particular pet or client. The records are benchmarks and serve as detailed written descriptions of each patient's medical condition, its progress and its resolution or outcome. In addition to the above purpose, medical records also facilitate rapid retrieval of patient and client information. Records also provide written documentation of medical decisions and client consents for legal purposes. This is providing protection to the veterinarian and clinic staff. Records also provide valuable statistical information about the client or pet population and how the practice should be headed to meet all the needs and wishes of the public it serves. The patient record comprises the core of the veterinary patient medical records and is therefore simply referred to as "the medical record" or "the pet's file". It contains the pertinent facts about the patient's life and health history.

Information to be recorded includes:
1. Owner's information
A. Names (Include different last names)
B. Address
C. Phone number - more than one is better, and an emergency contact may be good too. Include cell phone number if have.
D. Client workplace info and phone numbers.
E. Client financial status and methods allowed for payments of services.

Knowing that many people live together these days without being married, it often is best
to ask if there is a "co-owner" in the family rather than a spouse. Established clients should have the accuracy of their addresses and telephone numbers
verified at each visit. Changes should be made immediately.

2. Animal's Information
A. Species
B. Breed & colour
C. Sex and Reproductive Status
D. Age
E. Name
F. Source of pet and reason for owning pet
G. Tattoo/Microchip
H. Vaccine Hx
I. Pet's environment and care
J. Medical or physical conditions - ie. Declawed, deaf, blind, diabetic, epileptic, biter, aggressive, on going medications, etc.
K. Weight

3. All communication with owner - verbally, by phone, in writing..

4. All clinical signs and presenting observations.

5. All physical exams, diagnostic procedures, and laboratory tests.

6. All diagnoses or DDx.

7. All treatment protocols, surgeries, euthanasias, necropsies.

8. All daily observations of hospitalized pets and their health progress.

9. All prescriptions - with complete information.

10. All client completed forms and signed consents.

How is it Recorded?

Veterinary medical records are considered legal documents and as such must be treated by certain rules. All records must be written legibly in ink - preferably blue or black (never red), and never in pencil.
No records should be erased, whited-out or completely crossed off. Incorrect entries can only have a single line drawn through the incorrect information and initialed. The correct information should then be written down and again initialed. This indicates that an error was made rather than suggesting that information was changed or tampered with. All entries must be dated and initialed when entered.

Records can be recorded in one of two informational formats:
• As objective information
• As subjective information

Be aware that a veterinary medical record is considered a confidential document but is owned by the veterinary practice, not by the owner of the animal. Owners have no right nor legal obligation to have an original record. Any party (owner, insurance, another veterinarian) must sign a release form and then can only acquire a "copy" of the records. The only party privy to the original would be a legal court of law or investigating agency such as the police. Even when a pet owner moves to say another province, the originating veterinarian will only give the new attending veterinarian a copy of the files. The originating veterinary practice is required to retain all original records.

Objective Information

Includes factual, measurable data such as body temperature, fecal float results, x-ray interpretations.

Subjective Information

Involves the overall clinical impression of a pet and is not measurable by any standard. It can be as simple as a phrase such as "bright, alert & responsive".

Rules for Veterinary Medical Records

A. Veterinary medical records are an integral part of veterinary care.

B. Medical records are the property of the practice and the practice owner.

C. Ethically, the information within veterinary medical records is considered privileged and
confidential. It must not be released except by court order or consent of the owner of the
patient.

D. Veterinarians are obligated to only provide copies or summaries of medical records when requested by the client.

E. Without the express permission of the practice owner, it is unethical for a veterinarian to remove, copy, or use the medical records or any part of any record.

How Long Do You Keep Records?

Most records must be kept from 5-7 years. Check with local veterinary association. X-rays are also legal records and must be retained for the same period of time. Records may be removed from the main filing system (inactivated if the animal isn't coming in any more or if euthanized). But they cannot be purged and destroyed completely until 5-7 years have passed from the last entry.
Medical records are thus cycled out from a veterinary practice in three steps:
• Active files
• Inactivated or archived files
• Destroyed files
Files are often purged at least once a year or more often in larger and busier practices. Purging simply means that the files are cycled into or retained in one of the above states after reviewing of the file by clinic staff. Different clinics have different time frames for their files. Some may consider files as active if the patient has been seen within the past 6 months. Others may state an 18 month or even 36 month period. Any files considered inactive are moved to the "archives" which may simply be a series of storage cartons now residing above the back kennels. Inactivated files must be easy to retrieve should the pet/client reappear at the clinic. Records, being legal documents and containing personal information, must be shredded or burnt when completely removed from a practice's filing system. Purged X-rays will often be bought in bulk by silver recyclers.

Organizing Records

There are two primary formats of organizing the medical file. These are:
• The source-oriented veterinary medical record

• The problem-oriented veterinary medical record (POVMR)

Source-Oriented Veterinary Medical Record

This method, also called the conventional format, enters information into the record as it occurs chronologically. The file therefore ends with the most recent entry. The conventional format is easy to learn and requires less time to complete. In addition, this format lends itself to less voluminous medical records and different recording styles. However, it does lack the detailed documentation of procedures and their results and it makes retrieving information more difficult and time consuming.

Problem-Orientated Veterinary Medical Record (POVMR)

The problem-oriented veterinary medical record format provides a complete, accurate, detailed accounting on the patient. POVMR offers improved professional communication by providing a complete compilation of the patient's problem along with any treatments or procedures that may have been performed on the patient. It offers a comprehensive review of the patient including such info as:
- The patient's history
- The patient's medical problems
- Procedures and treatments done
- A proposed plan for the patient's care and future health

This format is more time intensive but it improves communication among staff in the clinic. It also provides more data for on-going patient care as well as being the best legal protection against potential law suites.

A POVMR usually includes several standard sections:
- Master problem list
- Comprehensive history form
- Physical examination form
- Collection of basic information, the data base
- Laboratory results flow sheet
- Medical procedures
- Progress notes or in-hospital record of patient

An important part of the POVMR is a master problem list. A problem is defined as anything that requires veterinary medical attention or care. It may be a sign that the pet's owner noticed or an abnormal finding from physical examination or a laboratory result. The master problem list serves as a mini history for the veterinary medical record file. It may list immunizations, fecal analyses, blood tests, ongoing medical concerns, on the dates these were found or done.
Progress Notes are daily recorded clinical notes about a hospitalized patient. These progress notes are divided into 4 sections as represented by the acronym SOAP. In the POVMR system, each of the problems noted with a patient is said to be "SOAPed". Any entries are recorded as to the pet's treatments and condition as well as communications with the owner or other veterinarians in chronological order. The key to this record system is to organize all the documents and forms in an efficient and consistent manner each and every time. You must become familiar with the system used in your clinic and then maintain the consistency. This consistency ensures that each animal gets the best care by keeping all pertinent information about the patient readily available for review by any staff member in the clinic. The proper order of the paper work in the medical file is the key to maintaining the consistency.

SOAP

S - Subjective information
O - Objective information
A - Assessment of the problem
P - Procedure or plan of action

Master problem list

MPL

Medication administration record

MAR

Dx

Diagnostic plan

Rx

Therapeutic plan

CE

Client education

Keeping Records Up to Date

One of the most important aspects of medical record keeping is accuracy. It is critical that each medical record always reflects up-to-the-minute information about a pet and the client. As the clinic receptionist, you will be responsible for all financial information, basic medical information, and the maintenance of an organized record storage and retrieval system.

Some tips for keeping the records up-to-date when speaking with a client:
• Always check that address and phone numbers are current.

• If an animal goes to another vet clinic ensure that record is added to your own.

• Weigh animals every time they come into the hospital.

• Always record prescription refills in the file.

• Record any telephone conversations with clients in the file.

• Ask client about pets not seen in a long period (dead?).

• Place sheets in file with most recent on top.

• Allow the master problem list to serve as an index for the rest of the record.

A

Assessment

POVMR

Problem Oriented Veterinary Medical Record (method of recording format)

RC

Recall - client needs to be called within or at a certain period of time.

RM

Reminder - for vaccine (v), heartworm (h), geriatric (g), pediatric (p) or dental (d) are pre-coded so they can be input into the computer for auto reminders.

TDx

Tentative diagnosis

Record Filing Systems

When a patient's medical record is not readily located, the statement "I can't find your pet's medical record" is an admission of a disorganized hospital. As such, clients instantly begin to lose confidence in you and our hospital's medical services. They will think, "if you cannot find my record, how on earth can you find, diagnose or treat my pet?"

Veterinary medical records are usually filed in one of two methods:
• Numerically
• Alphabetically

Numerical Filing Systems

Numerical filing is done by one of two formats: either each client is assigned a number or each pet is assigned a number. Normally each basic digit, 0 through 9, is assigned a different colour. File folders ( especially end-tab folders ) are used to hold the sheets of information for that pet or client and each folder will have varying colours depending on the assigned number. This system is invaluable in preventing chart misfiles and as a signaling device in the search for a specific record.
Numbers assigned can be based on various concepts:
• Phone number - keeps files of animals belonging to the same owner close together. But problems may arise when different people share the same phone number and when phone numbers change.

• Assigned number - Pets of the same owner may be kept in different areas of the file bank. But these numbers don't change or get assigned to other people unless the 7 year span is up.

Alphabetic Filing Systems

The client's last name is used as the file identification and as the method for systematic file storage. Each letter of the alphabet is assigned a colour, and the first 2 or 3 letters of the last name are attached to the end tab of the medical record folder. Then the files with similar beginning letters are themselves filed alphabetically. Because of the colour coding, it is easy to identify if a folder is out of sequence on the file shelf. Alphabetical systems are often found to be easier to file because you recall the client's name far faster but usually don't remember that many phone numbers.

Colour-Coding

Color can increase filing efficiency by 90%. Folders can be color-coded with one-piece strip labels according to the exact requirements. The most common color-coding systems (Alphabetic, Numeric or Terminal Digit) can meet any particular filing needs.

Pet's File

Record filing systems can be as easy or complex as desired. Most commonly every animal will have its own file. Occasionally, animals like puppies will be grouped together under their mother's file. Or breeders may have a file for various rarely seen animals if there are a lot.
Patient record file folders may contain a great many different forms, charts, documents, records and papers. The exact filing order of these pages will be determined by the particular veterinary clinic. Some examples of pages that may be in a folder can include:
- Client / patient information form
- History form
- Physical examination forms
- Master problem lists
- Laboratory test results
- Progress notes
- Telephone conversation forms
- Anesthesia records
- Surgical records
- Hospitalization daily record forms
- Client consent / authorization forms
- Euthanasia forms
- Fee-estimate forms
- Prescriptions dispensed forms
- Consultation forms
- Invoice statements
- Rabies/health /spay certificate copies
- Correspondence to and from clients or other veterinarians
- Dental records
- Absent owner forms
- Breeding records

Logs

There are many different logs that need to be maintained in a veterinary clinic. A log allows a quick check for necessary information without pulling patient files or going to other lengths to obtain information. Some governmental regulations require logs of certain procedures done or controlled substances used in a clinic. Many clinics operate on the principle that "If you use it, you log it".

Controlled Drugs

Essential for drug accountability with regard to narcotics, anesthetics, Log and other Federally controlled substances. Usually inspected periodically by Health Canada.

Anesthesia/Surgery

Helpful for callbacks, and to gather information on #'s of types of Log procedures, surgery times, and other stats. Date, animal's name, procedure, drugs used, length of time, people involved.

Dental Log

Similar to sx log.

Special Orders Log

Keeps track of client requests and when items have been ordered and picked up. Date, name, phone number, item they want (specifics), date ordered, date client called, date item picked up.

Reorder Log

Usually some place to write items that are running low (pharmaceuticals, testing agents, clinic supplies, vaccines, stationary, etc.)

Euthanasia Log

Helps to keep track of euthanol or other euthanizing agents, and whether cremation services were used or how the pet was disposed (need for accounting) Date, name, doctor, amount of euthanol, type of disposal.

Laboratory Procedure Log

Quick reference to see what tests were done for what animal what day, instead of checking files. May have one for in house tests
and one for samples sent to outside laboratories. Name, pet, date, what was done, results.

Courier Log

When was courier called, and when was item picked up. (For accounting)

X-Ray Log

Quick reference to note when and what technique was used for particular pet. Record client, pet, date, body part, positioning, exposure settings, films used.

Maintenance Log

Ways to make sure that certain maintenance is done at certain intervals, and to check back to see what has been done. May have one for every clinic machine or piece of equipment.

Cash Out Log

Record of cash drawer balancing - problems, date, people involved.

Boarding Log

Owner, pet, duration, which kennel, problems, when discharged, fee.

Grooming Log

Owner, pet, type of cut, any products used/dispensed, sedation if used.

Cleaning Log

How often things need to be cleaned, and whether it was done and who did it.

Fax Log

Who sent, from whom received, problems, date & time.