Medical record keeping violations are once again a hot-button issue with the Veterinary Medical Board (“Board”). And so it is important that licensees are aware of the serious consequences and what can be done to avoid them and catching the Board’s ire.
Importance of Record Keeping
But first, keep in mind that the overall goal in record keeping in the first place is not to avoid license discipline or professional malpractice. Well, at least it should not be. Rather, the primary purpose of complete medical records is to be able to provide the best animal care possible. Not just in the instant you are caring for the animal with the malady it is suffering on that particular day. Rather, two, five, or even ten years down the road when that animal comes back and a check of their records is required to assist the care provider at that time with determining how best to help that animal. And while some care providers may possess photographic memories, those memories are to no avail if the animal is being seen by a different licensed professional.
Most common violations
The cause of the most common record keeping violations can span from carelessness to just plain lack of records. Both are inexcusable; it is imperative to keep proper medical records. Some of the other issues we have encountered are the records are not legible; they do not include all treatment provided to the patient, medications/prescriptions and the dosages, or who is responsible for the care provided.
Other issues include not providing complete records to the Board when requested. When a complaint involving a veterinarian is filed with the Board, the subject of the complaint is asked to provide extensive information in his or her defense. One of the most convincing pieces of evidence the veterinarian can present is a thorough medical record. Medical records include the medical chart, labs, x-rays, radiographs and other notes taken regarding the patients care or treatment. All records must be provided when the Board requests medical records. However, many licensees – even those with impeccable records – get scared and fail to respond.
Requirements and Tips
The conscientious veterinarian who wants his or her records to accurately reflect treatments, procedures, and conversations shouldn’t need to spend more time on maintaining medical records than caring for patients. The solution is to be as efficient as possible. You can review the requirements for medical record keeping by licensees specified by California Code of Regulations, section 2032.3 on the Board’s website. That said, here are some further tips:
- There should never be more than one set of records.
- If a pet owner asks for a copy of the medical records, they should receive a true and correct copy of the medical records.
- If medical records are altered after the fact, the addition should be noted that it is a subsequent entry with a signature of the party making the change and date. The Board will otherwise assume that the altering of the medical records was done with fraudulent intent according to California Code of Regulations, section 2032.35 on their website.
- Use commercial or customized stamps, stick-on exam labels, and preprinted medical record forms to minimize the repetitious part of record keeping.
- Use customized or standard medical abbreviations. The generous use of abbreviations greatly reduces the volume of material that you must write. Make sure you maintain a list of abbreviations that are used, so that every practice employee can decipher your records.
- Enlist your staff to help with the record keeping chores. Every staff member should be trained in the art of record keeping. All hospital employees should record their conversations with clients in the medical record. Technicians and assistants can help with documenting treatments and progress notes. Have each individual initial their entries in the record.
- Pre-printed anesthesia forms are an easy way to provide proof of the great job you and your staff do monitoring your anesthetized patients.
In the Veterinary Medical Board’s Disciplinary Guidelines, it states that a written record violation maximum penalty can be license revocation with a $5,000.00 fine. A minimum penalty can range from revocation and/or suspension stayed, two-year probation, standard terms and conditions, 30-day suspension, $1,000 fine, and optional terms and conditions including but not limited to continuing education.