The Do’s & Don’ts of Medical Record Keeping
The purpose of patient medical records is to document the patient condition and medical care. Thorough medical records are crucial in defense of a veterinary malpractice claim and a license/board complaint. Appropriate documentation is needed to support that the treatment met the standard of care.
In this issue, we will present the do’s and don’ts of medical recordkeeping, provide helpful advice from our malpractice carrier on what should and should not be included in the medical record and client communication log.
Medical Recordkeeping Do’s
DO regularly check your state veterinary practice act/rules for the medical recordkeeping requirements. State requirements vary on items such as what is required to be in the medical records, and how many years medical records must be kept. Failure to keep medical records according to state law can result in discipline if a license complaint is made against a veterinarian. (In Indiana, animal recrds must be kept for 3 years from the date of the last treatment.)
DO keep complete medical records where all entries are legible and signed or initialed. Include signed consent forms, treatment logs, anesthetic and surgery reports.
DO write clearly and concisely so that the record can be easily understood.
DO document all medical and surgical care provided to the patient in a timely fashion. If a late entry is required, make an addendum to the record dated the day you make it.
DO document all recommendations and treatment plans and note if treatments or referrals are declined.
DO follow all state requirements regarding patient confidentiality. Only release medical records if you receive a request from the client/owner or from your state board.
DO consider whether medical records software will help improve your practice’s recordkeeping.
Medical Recordkeeping Don’ts
DO NOT include the following items in the medical record: notes that a claim has been reported; any communication with AVMA PLIT, your insurance carrier, or your attorney about an incident or claim; or any communications with the state veterinary board or a board investigator.
DO NOT make any disparaging statements about any client/animal owner. Keep all statements about the client factual.
DO NOT discuss your claim or lawsuit in public or on any websites or social media platforms, including any sites or groups that are considered “private” or related to the veterinary profession. Your statements may be discoverable in a lawsuit and be used against you.
Keep a Separate File for Claim-Related Materials
Any materials related to a claim or litigation should be kept in a separate file. The file should be marked with name of the owner/client. That file can include notes, narratives, case assessments, social media comments, emails, or correspondence. Access to this file should be limited and controlled. If more than one veterinarian is involved in the claim, separate files should be maintained for each. Placing this information in the medical record or sharing it with a third party may waive any privilege or confidentiality, making it subject to disclosure in litigation or a board complaint. The people who can access the file without waiving privilege or confidentiality can vary by state but typically include the veterinarian reporting the claim, a dedicated practice “risk manager” (if the practice has such a role), your legal counsel, and appropriate insurance representatives.
Client Communications Notes/Log
If your practice maintains a “Client Communication” file or log separate from the patient’s medical records, the following items should be kept in it:
- Notes about the client threatening to sue or filing a suit
- Notes about verbal and physical threats/ assaults by a client
- Notes about calling the police or filing a police report
It is beneficial to document what the client is threatening and/or the client’s behavior. Be factual in what is documented in the medical records and client communication log. Do not add opinion or commentary about the client or their behavior. These suggestions also apply to writing emails or text messages.
Does the client communication file/log have to be provided if a client requests the medical records?
It depends on what your state’s practice act, statute, or administrative rule says. However, you should presume that the client communication log will be discoverable by the board during a board complaint or if a lawsuit is filed. In other words, expect your client will see what is documented in the client communication log.