College Connection | Summer 2025
Medical records help Panel understand member’ s reasoning
College Connection | Summer 2025
LEARNING IN PRACTICE
Medical records help Panel understand member’ s reasoning
Case Summary
The member examined a cat with a swollen eye and discharge, loss of appetite, and weight loss.
The member collected blood samples, administered vitamin B12 and subcutaneous fluids, and prescribed ophthalmic drops, pain medication, and a prescription diet.
Later that night, the cat was taken to an emergency hospital in critical condition and was euthanized. The client claimed the member failed to provide appropriate care, did not disclose the severity of the cat’ s condition, did not adequately discuss pain management, and performed unnecessary testing.
Case Outcomes
The Complaints Committee panel decided the allegations did not warrant a referral to the Discipline Committee, and that no further action would be taken.
Based on the available information it appeared the member had discussed referral for emergency care, pain management, and diagnostic options with the client. This discussion was documented in the medical records.
In this case, medical records helped the panel understand the member’ s clinical reasoning, the options presented to the client, and the care provided. The records were essential in the review and resolution of the complaint. The panel was satisfied with the care provided, and the diagnostic tests performed appeared appropriate in the circumstances
Case Considerations
In considering the complaint, the Complaints Committee panel reviewed the medical records, written submissions, and statements provided by all parties. The panel also considered typical veterinary practices related to diagnosis, pain management, and client communication.
The member explained they had discussed the cat’ s poor prognosis, the option for referral to emergency care, and euthanasia. These conversations were witnessed by clinic staff and documented in the medical records. The client was presented with appropriate diagnostic and treatment options, and it was the client’ s choice to pursue outpatient care.
The records included detailed documentation of the cat’ s clinical signs, such as a swollen left eye with a bloody anterior chamber, tachycardia, generalized muscle loss, and a distended abdomen, as well as the findings from the physical examination. The records also reflected that the member reviewed diagnostic and treatment options with the client, including bloodwork, urinalysis, radiographs, and humane euthanasia. The client’ s decision to proceed with bloodwork and supportive care was noted, along with their concerns about cost and their wish to keep the cat comfortable through the holidays.
This was a stressful and challenging situation for the client. The client’ s decision to proceed with humane euthanasia, following the cat’ s deterioration, likely caused significant grief and emotional trauma.
References
The College offers a range of tools to assist you with your medical record keeping:
• Professional Practice Standard- Medical Records
• Guide to the Professional Practice Standard- Medical Records
• Peer Review of Medical Records
• Learning Modules
Veterinarians have a responsibility to provide safe, quality care. The College assists veterinarians in doing so when matters are reviewed by the Complaints Committee. The public has a right to ask questions about the care that was provided to their animal( s) and this process provides veterinarians with feedback on whether they have met the standards of practice or whether there are improvements needed to mitigate risks in practice. The Committee provides advice or may request a veterinarian enter into an undertaking when remediation would reduce risks and support a veterinarian in meeting the standard of practice. Only the most serious cases, where there is bad intent, incompetence, reckless behaviour, or a history of failure to remediate at-risk behaviour are referred to the Discipline Committee for a discipline hearing to determine if an act of professional misconduct or serious neglect may have occurred. This example is taken from a case that was reviewed by the Complaints Committee and is offered as a self-reflection tool to support veterinarians in understanding how to meet the standards of practice.
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