Painless Medical Records
Philip J. Seibert, Jr., CVT
The veterinary computer of the 1990s holds a great "client record" but the written patient medical record is required for continuity of quality patient care. Dr. T.E. Catanzaro, MHA
Continuity of care and forensic concerns are the basis of today's medical records, but most practices still keep medical records like they did when it was a feedlot operation. The role of the animal in today's society has evolved. Whether a practice is accredited or not, the American Animal Hospital Association (AAHA) sets the medical recordkeeping Standards for the entire profession. With the advent of computers, a confusion fell upon the veterinary profession. The great programmers in the sky linked fancy cash register programs to word processing programs and call them "veterinary specific" software databases. The expected evolutionary changes occurred; the veterinary systems gained more "bells and whistles". Windows software (user-friendly, memory heavy, icon screens) started to appear in 1993; Windows may be the first step to revolutionary changes. A true veterinary medical computer would have a relational database driven from the PROGRESS NOTES, not the invoice. Today's practice has found a way to use all the tools at their disposal to enhance the information in the medical record while simplifying it at the same time.
1. Computers are great for client relations and tracking income centers; a few even have the capability to handle accounts payable.
2. Medical records (hard copy) are for professional communications between providers; they should ensure a continuity of quality care. The Problem Oriented Medical Record (POMR) is a documentation requirement which is here to stay; it is what defeats the lawyers in court!
3. The "forms" must be tailored to the practice and the philosophy of the veterinarians in charge; there is no single standard of "completeness." In a practice of dedicated and trained veterinary healthcare providers, forms just support their effort. In a veterinary practice of people just doing their job, forms generally replace caring and thought, so forms and procedures get too detailed and too cumbersome.
a. Forms going home with clients REQUIRE the practice logo and phone number. Forms being used "in-house" require neither of these, but do require client and patient names.
b. Most clinicians prefer head-to-foot printing for medical record forms, so they can turn up the page and keep writing on the back without undoing the prong, but that is because we prong papers at the top of the page. The attachment (prong placement) of the pages are a personal preference but must be considered when designing any medical record forms.
Here are the FACTS OF LIFE when it comes to recordkeeping in the veterinary profession:
1. There are practices with an 89% compliance to full preventative services at first visit, and others that have a current vaccination status within 5% of the initial visit vaccination status.
2. The "pets over 24 months since seen" are mostly those from single visit clients (often grooming, bathing or boarding contacts) or multi-pet households where the health status of other pets were not recorded when one pet of the family was presented for care.
3. While some medical record data reflects "violations" of internal policy or quality patient care, it is more often attributed to failures in the documentation process. These type of "failures" in documentation often lead to internal control problems, liability/forensic concerns, embarrassment of the practice or client, or a reduced value per pet seen. The bottom line is that these trends reduce the continuity of care value of the medical records as well as the liquidity of the practice.
4. When one hears a receptionist say "that part of the medical record is not my concern," there is a systemic problem. Any divided POMR system is a perfect example of inefficiency looking for a place to destroy the continuity of care. Practices needs to consolidate medical record responsibilities under the lead receptionist. The world of veterinary healthcare considers the medical record folder system as the standard, replacing the hanging pocket systems (ANCOM, ProFiles, etc.); terminal-digit medical record file folders on open shelves are augmented with high density filing systems that mediate space limitations enough to make this alternative a viable option.
5. The value of good medical records can be seen with better continuity of care for patients, but also has a litigation protection value. Legal concerns seen during our frequent medical record audits (100 records from a single practice, done in over 100 different practices this decade) included: no client complaint (reason for access), tumor surgery without client permission being recorded, no admission action noted, medication prescription with reason, recurrent cardiac dysfunction patients treated with Lasix with NO diagnostics or follow-up recorded, surgery for pets without reason for surgery being noted in the medical records, no dental status/weight/TPR in multiple visit pets, lack of presurgical assessments, treatments without reasons, inpatient care without vaccinations or client waiver, no discharge planning, records contradicting themselves or being ignored in successive entries, or ambiguous statements such as "shots current" without an approximate date.
A few consultant tips are offered here before you read further:
a. Don't pre-qualify failure by stating there isn't enough time to document quality veterinary healthcare delivery.
b. Written versus delivered quality is an argument that will occur, but build the new habits before addressing this issue.
c. A twenty percent discount in fees to get more clients will require double the number of clients to reach the same break-even point as the pre-discount fee schedule.
d. Record everything that is done, as it is done; most practice acts do not let veterinarians hide their healthcare delivery. Even a complimentary nail trim during surgery should be recorded, since and adverse sequelae might be cause for litigation or complaint.
e. Charge for everything that is done. If the invoice total is a concern, either adjust the bottom line total or schedule supplemental care at the recheck visitation, thereby spreading the expenses over a period of time for the client.
Putting it Together
The procedure tracking sheet for services (circle sheet, speed sheet, travel sheet), a new client welcome form, a well designed patient data cover sheet, and the progress notes are critical summary points in this revised documentation process. These medical documents can be good for the practice only if they are used as designed; this is seldom the case in the records audited. While the procedure tracking sheet, new client form, and patient data cover sheet are summary forms, the progress notes are the record of care, the record of needs, and most important, the record of client desires, waivers, deferrals and other important decisions.
The medical record progress notes are the cornerstone of any health care delivery program, and substantiates the charge sheet. It also allows the veterinarian in the practice to follow a case and ensure continuity of care. When visits are summarized on the patient data cover sheet, these summaries can provide additional income for the practice when all animals in the household are screened whenever one family animal is presented; it could be called a herd health program for companion animals. To do less is not quality medicine, concerned care, or comprehensive service expected from an outstanding staff.
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