Seton Butler, VCNZ

Clinical records under the microscope

VCNZ’s Seton Butler looks at the role and requirements of clinical records in veterinary practice. How important are they, and how’s your compliance?

THE CODE OF Professional Conduct, under the Veterinarians Act 2005, states that Veterinarians must maintain clear and accurate clinical records.

WHAT IS A CLINICAL RECORD?

A medical record is a legal document that represents a veterinarian’s thought processes, decisions, judgements, actions and interactions with others including clients, colleagues, other caregivers, specialists and laboratories. It’s also a communication tool that facilitates continuity of care for animals, both within and between veterinary care teams.

WHAT DOES ‘CLEAR AND ACCURATE RECORDS’ MEAN?

According to the code, clear and accurate records: show an adequate and accurate history; contain an adequate record of the physical and clinical examination; contain detail, where indicated, on the environment in which the animals under investigation are kept; contain evidence of adopted treatment strategies; retain evidence of consent to the treatment plan strategies.

Try using the problem-oriented veterinary medical records plan – either SOAP (subjective, objective, assessment/ analysis, plan) or HEAP (history, exam, assessment, plan).

WHAT DOES THE CODE SPECIFY FOR CLINICAL RECORDS? The code states:

The records must be of such detail that another veterinarian could take over the management of the case at any time.

A veterinary consultation must include the veterinarian collecting and recording sufficient information relevant to the individual circumstances to ensure the proposed course of action (including treatment) is appropriate to meet the needs and best interests of the animal(s) and client.

Veterinarians also have a responsibility to provide information to clients to prevent any residues showing up in produce as a result of treating an animal with a veterinary medicine.

Veterinarians must facilitate the traceability of RVMs that have been authorised for use in production animals: They must ensure through their own clinical records; records of written authorisations they have provided to clients; and labelling of products they have dispensed that the treatment of an individual animal can be linked back to a specific authorisation.

Over and above the pride we take in doing a good job, clear and concise clinical records can be crucial to a veterinarian’s ability to defend their actions. They provide powerful evidence of the circumstances of a case, what was said and what was done – and that’s good!

Where more than one veterinarian is providing services to the same client the general principle is that the veterinarians concerned, with the client’s consent, liaise and share relevant information.

When asked to provide clinical records about an ongoing clinical case to another practice … The provision of relevant clinical records ensures that all veterinarians providing services to the animal(s) have relevant historical clinical information.

This makes sense if we want to ensure the best outcomes for animals and their owners. It preserves a client’s right to use the services of more than one veterinarian or to seek a second opinion and for the veterinarian it avoids embarrassment should another veterinarian or insurer read the records.

Clinical records belong to the owners of the veterinary practice. However, the information in them is the client’s.

Clinical records should contain all relevant information including case notes, X-rays, lab results, drugs used and treatment details.

Individuals have the right to access the personal information held by veterinarians about themselves (including information about their animals).

This suggests to me that we have a responsibility to ensure information is accurate and complete.

Veterinarians must make practice records available to inform any review of their competence.

At times I wonder if this has a counterintuitive effect on veterinarians, where they think, “If I don’t write anything they can’t prove I’m incompetent”.

I believe the intent is that as long as a sound process is followed, even if there are decision errors along the way, it is far better than no obvious process at all. VCNZ understands we’re all human and knows that no-one has practised error free... ever!

PUTTING RECORD-KEEPING INTO THE HUMAN CONTEXT

On reflection, I believe that not maintaining appropriate clinical records would be letting down the animals we serve and care for, our clients, not to mention ourselves.

In the context of my own health, I would expect no less (and probably more) than a good standard of record-keeping from my health practitioner... so why would we expect any less from veterinarians?