Jan 11 2018

6 tips to improve your medical records

Taken from the AVMA Professional Liability Insurance Trust Quarterly newsletter:

When a client alleges malpractice, one of your key defense tools is the patient’s medical record. Attorneys often say that if it is not documented, it did not happen.

1. Document medical treatment plans and have clients sign consent forms
2. Document client declinations of recommendations or procedures
3. Document communications including phone calls, emails, texts and verbal conversations
4. Document history of complete physical exam and procedures including detailed anesthetics and surgical reports
5. Document boarded patient information such as elimination, appetite and weight, especially for medical borders
6. Use computer-based record system or ensure handwritten material is legible

Any veterinarian should be able to pick up treatment of a patient where you left off by reading your records.

Avoid these medical record mistakes:

1. Illegible entries
2. Inappropriate entries
3. Failing to document recommendations and owner declinations
4. No consent forms
5. No documentation on boarded animals, especially medical boards (such as diabetics)
6. Lack of records, incomplete information
7. No anesthetic drugs, doseages, anesthetic monitoring entries
8. Incomplete charting of physical examination
9. No surgery report, no suture or sponge count information

Steve Simmons | News and Articles

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