QUALITY PRACTICE
PRACTICE ADVICE
MEDICAL RECORD MAINTAINS CONTINUITY OF CARE
A medical record is an important tool a veterinarian uses to help maintain continuity of care for their patients . Patient records can also support effective client communication .
Veterinarians have a professional obligation to maintain complete and comprehensive medical records to help mitigate risks to the patient , the veterinarian , and the client . However , according to a 2018 survey of members of the Ontario Veterinary Medical Association ( OVMA ), for many veterinarians , writing medical records is seen as a burdensome , time consuming task that takes them away from providing quality patient care and is affecting their overall work / life balance . They may struggle with finding a method for record keeping so that it feels less onerous . Factors such as misinterpretation of the requirements , approach to record keeping and concerns regarding not having enough information written down appear to contribute to the issue .
To be complete , patient records do not need to be lengthy . Quantity of record information does not necessarily equate to completeness . Quantity can even potentially compromise the continuity of patient care because another veterinarian reading that record may miss important details when trying to scan a record before seeing the patient .
For a record to be comprehensive , ensure the regulatory requirements are met ; that there is enough detail to maintain continuity of patient care ; and there is an understanding of the veterinarian ’ s thought process and reasoning behind a diagnosis and decision for treatment plans . Organized , succinct records can be complete and are more efficient to maintain . There are many tools that can help achieve complete and concise patient records .
The use of the SOAP ( Subjective data /
Objective data / Assessment / Plans ) or DAP ( Data / Assessment / Plans ) format to organize patient records will help to ensure regulatory requirements are met . Using templates and protocols within the SOAP / DAP format helps with completeness and efficiency . Examples of templates include history taking and physical exam findings . In-hospital monitoring forms , anesthetic monitoring forms , discharge summaries / instructions , and Standard Operating Procedures ( SOPs ) are other examples of template documents that can be developed to help build in record keeping efficiency .
Protocols can be developed for surgical procedures , physical examinations , and vaccination administration , to name a few . A protocol is a detailed description of a procedure that is done routinely and is maintained for reference . A notation in the patient record would indicate that a procedure was done “ as per protocol ” and any information specific to the patient and / or any variation in the protocol would be recorded .
Duplication of information is not necessary and can be time consuming . For example , if an anesthetic monitoring form is used , this will be part of the patient ’ s record . The information on the form does not need to be documented within the progress notes section as well . A notation such as “ see anesthetic monitoring form for details ” would reference where this information can be found .
Documentation in a patient record does not need to be in full sentences .
Point form notes are faster to make and are easier to follow . Abbreviations can be used as well . A master list of abbreviations is recommended so that all staff members are aware of their meaning . If records are transferred to colleagues , the abbreviation list should be included .
Aspects of record keeping can also be delegated to auxiliary staff members . Staff members should be aware of record keeping requirements . As records are ultimately a veterinarian ’ s responsibility , oversight is required to ensure records are complete and appropriately documented . The language used by all staff members when writing in a medical record should be professional and objective and should avoid subjective and derogatory comments . A medical record is a permanent and legal record and it is important to ensure that the tone is professional in nature .
The College has many resources to help with medical record keeping . These include :
– Sample documents
– Foundations for Medical Record Keeping Learning Modules
– Peer Review of Medical Records Program ( self-assessment questions are available and / or a veterinary facility can volunteer to participate to receive feedback on records )
– Professional Practice Standard and Guide on Medical Records
– Practice Advisory Service
– Minimum Standards for Veterinary Facilities in Ontario
A quality medical record is fundamental to quality practice . Consider evaluating your record keeping system to identify opportunities to incorporate strategies in this article to help make record documentation more efficient and effective .
4 College Connection Fall 2020 cvo . org