Dr. Jake Peregrine1 wrote the following surgery report: “cherry eye removal; excessive bleeding; Lasix/dex/pen/atropine.”
After the patient, a Cane Corso, died, the client filed a complaint. The board found that the medical records violated its regulations on multiple counts, including lack of:
- Documentation of the patient’s hospital care and treatment
- Proper notes, written in a problem-oriented fashion (or other similar format), which would allow any vet to follow their colleague’s thought process
- Identification of the treating person after each chart entry
- Date of each exam
- Dosages of anesthesia and dispensed drugs
- Written consent form
- Discussion of benefits and complications of treatment
- Documentation of anesthesia monitoring
- Full physical exam prior to anesthesia
- Offer to perform pre-anesthesia blood work
- IV fluids during anesthesia
Our colleague may have argued that he did perform a physical exam, that the patient was monitored and that he did receive IV fluids.
Sadly, that’s irrelevant to this (true) story. In the legal world, “If it’s not written, it didn’t happen.” In addition, the fact that he performed the surgery in the back of a pickup truck in 90-degree heat did not help his cause.
In the end, Dr. Peregrine was found guilty of incompetence, gross negligence and malpractice. His medical records were deemed “deplorable,” and the board mandated him to:
- Take a comprehensive course in veterinary medical records
- Complete eight hours of CE in anesthesia
- Pay a penalty of $21,200
- Undergo a six-month license suspension
Think this could never happen to you? Have you ever written “routine spay” or “standard closure” or “usual protocol” in a chart? Do you not have an anesthesia and monitoring record for each patient? Don’t you do dental charting? If so, you’re not in compliance.
Medical records are often considered a chore, a time vampire or a necessary evil—until you need to take over caring for a colleague’s patient, that is, or until you receive a nice letter from your friendly veterinary board.
The rule is that “a medical record should be maintained in a manner such that another veterinarian could, by reading the record, proceed with the proper care and treatment of the patient.”
That’s usually when you wish the handwriting were more legible, the notes more thorough or the treatment plan was more detailed.
If you don’t document that your patient does not have a heart murmur, one could conclude that you did not auscultate the heart. If your records don’t say that your anesthetized patient had an endotracheal tube (including its size), then one could assume that he did not have one. If your technician did not log a sick patient’s temperature (her job; ultimately your responsibility), one could presume that you did not know the animal had severe hyperthermia.
“This is one of the biggest misconceptions in record-keeping,” explained Teresa Lazo, board counsel at the Pennsylvania State Board of Veterinary Medicine2. “Veterinarians and technicians often believe that they only need to document abnormal findings in their records, but that is not true. Pretty much everything that happens to a patient should be documented, from the minute they walk into the practice until the moment they leave.”
A complete patient’s record should mention: complete signalment (including weight and gender), the history and client’s complaint, vaccination and preventive health history, initial assessment, detailed prescriptions, diagnostic test results and interpretation, diagnosis (or at least tentative diagnosis), etc. Medical records should be legible, and every entry should be signed or initialed.
There are no rules on the timeframe for completing a patient’s record. However, important information can be forgotten over time. Some details can elude you after you see several patients in a row without writing up your records. In addition, if that patient ends up at another hospital or the emergency clinic the evening of your exam, that practice might be interested your most recent findings and treatment. Ideally, record-keeping should be contemporaneous.
Include a cover page with all diagnoses or procedures performed. Medical records should include all clinical information to support the diagnosis and the treatment given. The medical record is also used as a communication tool among staff members to carry out treatments, document patient status and track patient progress.
If a patient is admitted for a procedure, everything done or observed should be noted in the record and initialed by the team member. If there is no mention that food or water was given, one could assume that you failed to offer anything to the patient for the entire time it was under your care.
Alternative options, complications and risks of a surgical procedure should be discussed with clients, and there must be a written trail of that discussion. Otherwise, a board member or a lawyer could assume that it didn’t happen. A standard consent form can be used as long as it details any significant risk and verifies that the veterinarian has discussed them and answered the owner’s questions and concerns.
Details, Details, Details
Whenever a complaint is made after a complication occurs, the client will invariably say “My vet never told me that XYZ could happen.” True or not, your only protection is a detailed, signed consent form that includes specific risks and complications of the procedure, including the risk of death.
In addition, in Pennsylvania, clients must be informed clearly whether someone will be on the premises while their pet is hospitalized after hours.
Regarding anesthesia records, include the drugs given, concentration, dosage, volume, route and time of administration, and the name or initials of the person who gave them. Include in the record the inhalant anesthetic used and whether it was delivered with a mask or an endotracheal tube. Record vitals every 5 to 10 minutes during anesthesia, in addition to the flow rate of oxygen and inhalant.
“Common mistakes include failure to write drugs given in house or dispensed, failure to record vital signs during sedation or anesthesia and failure to document the physical exam,” explained Teresa Lazo. “It is not acceptable to only document abnormalities. A check-box system with various body systems and the mention normal/abnormal is acceptable.”
Detail the surgery. “Routine spay” is pretty much meaningless to a lawyer. Multiple spay techniques exist, not to mention multiple types of suture material and suture patterns. Abnormal findings should be documented.
Monitor and record recovery. Again, if nothing is documented about the recovery period, one could assume that nobody monitored the patient, and you could be liable for complications.
Provide postop, detailed, written discharge instructions that outline the importance of wearing an e-collar, how and when to give medications, what to monitor, when rechecks are needed, etc. And, of course, keep a signed copy in the medical record.
Medical records are confidential and owned by the practice. They can be copied and released only if requested by the client or by the law. No staff member should be allowed to remove medical records or even parts of them from the practice.
What if you are “paperless” or “paper- light?” Maintaining digital records certainly helps eliminate multiple problems, starting with poor handwriting. Just like paper records, include the patient, client and clinic information in digital records. The software usually will have a spot for the physical exam, the diagnosis, the treatment and prescriptions. It might link X-rays and blood work to the patient.
The bottom line: write up medical records thoroughly and legibly. It’s the cheapest form of insurance you’ll ever have.
- Clearly not his real name (movie buffs will get it).
- The information provided is based in the Pennsylvania rules and regulations, but for the most part, the same concepts apply nationwide.
Dr. Phil Zeltzman is a board-certified veterinary surgeon and serial entrepreneur. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. Visit his website at DrPhilZeltzman.com, and follow him at facebook.com/DrZeltzman.
Kelly Serfas, a certified veterinary technician in Bethlehem, Pa., contributed to this article.