Excellent veterinary medical recordkeeping protocols are core to the ability to deliver quality care to patients. It is not possible to overstate the value of accurate, clear, and complete medical records. Unfortunately, medical records are often delegated to the "I will do them when I get a chance" pile and important information is either forgotten or misremembered. Also, even when handled promptly, poor recordkeeping protocols result in incomplete records that are often hard to read and confusing.
Take an honest appraisal of the recordkeeping requirements at your practice. What if a number of months after seeing a patient the animal's owner decided to take the practice to court in an attempt to prove malpractice? Would the patient's medical record serve as non-verbal proof of quality care or would it reflect poorly on the practice? Would the medical record help or hinder the practice's defense? Most veterinary professionals have heard that if it is not in the medical record "then it didn't happen." Often it is the gaps in the medical record that speak the loudest.
Medical records provide a road map, from start to finish. Is the path clear, with each step along the way documented and the plan for the next step clearly laid out? Or is it a confusing jumble of halting steps without clarity and focus? Could another professional, totally unfamiliar with the patient, pick up the medical record and immediately understand prior history, testing, differentials, treatments and patient response? Is client consent and client refusal for recommendations legally documented? Does the practice's medical records aid in increasing patient follow-up and client compliance?
Medical Records: The Roadmap to Quality Care is a 3-week course that provides the foundational knowledge needed to develop sound practice protocols for all members of the veterinary practice team.