college connection
LEARNING IN PRACTICE
Members of the veterinary profession have a responsibility to uphold standards to ensure the public has access to safe, quality
veterinary care. When those standards are compromised, the College responds. Every veterinarian can learn from these
situations and publishing the details of complaints received and resolved is intended to support that learning. The example
below is taken from an actual complaints case and is offered as a self-reflection tool to improve practice across the province.
MEDICAL RECORDS FOR LITTERS CANNOT BE COMBINED
CASE SUMMARY
The member examined five puppies and
found them in good health. A few days later,
he examined five more from the same litter
and also one of the previously examined
puppies with concerns she was less active
and had a poor appetite. The member
administered lactated ringers subcutaneously
and dispensed dewormer.
A couple of days later, the client indicated
some puppies had bloody diarrhea. No
parasites were found and the member
prescribed an antibiotic and a supplement to
support the gastrointestinal tract.
The next day, three puppies died. Two
puppies were admitted for IV fluids and
antibiotics and one passed away overnight.
The client told the member another puppy
from the litter had been adopted out without
examination or vaccination and had fallen ill
and tested positive for parvovirus.
The remaining puppy stayed in the hospital
on IV fluids for a couple days and continued
to improve. The puppy was sent home with
an antibiotic and instructions to force feed
as required. About a month later, it was
reported the puppy was doing well and had
normal stools. A parvovirus test was negative
but a fecal float indicated the puppy had
roundworms and coccidian.
The next month the client discussed
the invoice and offered to pay half and
suggested the member was responsible
for the death of four puppies. The member
offered to cover the entire balance but also
indicated the client would no longer receive
veterinary services from him.
CASE OUTCOMES
The panel decided the nature of the
allegations involving the member did not
warrant a discipline hearing.
In consideration of this complaint, a panel
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reviewed the material provided. As is
standard practice for investigations, the panel
considered previous proceedings against the
member. • Each patient requires a dedicated
medical record. It is inappropriate to
combine medical information about
puppies in one record.
In the panel’s opinion, it would have been
prudent for the member to run a parvovirus
test immediately upon being presented with
puppies who displayed signs of illness. The
panel decided to offer advice to the member
about this issue. • The medical record must include the
results of daily examinations, including
weight which is crucial in the case of
young, unwell puppies.
• When hospitalized, a patient’s medical
record must include a list of differential
diagnoses, details of medication
administered and documentation of
client communication. A discharge plan
must be clear and it must be provided to
the client, preferably in writing
The panel relies on the medical record to
substantiate the care provided. In this case,
the medical records were scant and did not
include complete information. The panel
provided advice to the member about record
keeping.
The panel reviewed the information pertaining
to the termination of services in this case
and noted that while a veterinarian has the
prerogative of terminating the Veterinarian-
Client-Patient Relationship (VCPR), this must
be done in accordance with the provisions
of the College’s standard. In this situation, it
appears that the termination of services was
not conducted appropriately. The notice of
termination was not provided in writing as
required by the standard and the client was
not given information pertaining to emergency
veterinary care for his dogs. The panel
expects terminations of the VCPR are done
according to the standards of the College
and the expectations of the profession.
Advice is meant to be educative and serves
as a remedial tool to assist licensed members
in correcting areas of practice identified
as problematic. Such advice is intended
to provide education about standards and
expectations and/or changes necessary so
similar concerns do not arise again.
CASE CONSIDERATIONS
The panel provided the member with advice
about medical records:
Proper record keeping is an integral
component of veterinary practice. The
College’s Professional Practice Standard,
Medical Records indicates the “complete
medical record is a compilation of all
information that pertains to the care of an
animal… and documents the management of
a case. It is a legal document that represents
the veterinarian’s thought process, decisions,
judgment, actions and interactions with
others… each of which has an impact on
patient outcomes. The medical record is also
a communication tool which facilitates the
continuity of care for animals both within and
between veterinary medical-care teams.”
For further learning
opportunities on this case:
Medical Records
Professional Practice Standard Medical
Records
Webinar Series - Foundations for Medical
Record Keeping (companion animals)
Medical Records Self-Assessment Tool
Veterinarian-Client-Patient Relationship
Professional Practice Standard VCPR