General Recordkeeping in Veterinary Practice
by Jeffrey L. Roth, JD
Whether you are practicing in a large animal, small animal or mixed practice, there are many sources for recordkeeping requirements related to the practice of veterinary medicine. Veterinarians in Alabama are subject to state law, federal law, and requirements imposed upon them by professional associations.
The American Veterinary Medical Association’s (AVMA) Principles of Veterinary Medical Ethics requires veterinarians to maintain medical records if a veterinary-client-patient relationship (VCPR) exists. A VCPR exists when a veterinarian has assumed responsibility for making clinical judgments regarding the health of an animal, and the client has agreed to follow the veterinarian’s instructions. The veterinarian must have sufficient knowledge of the animal to indicate at least a general or preliminary diagnosis. This means that the veterinarian has recently seen and is personally acquainted with the keeping and care of the animal by examination of the animal, or medically-appropriate and timely visits to the premises where the animal is located. The veterinarian also must be readily available, or have arranged for emergency coverage, for follow-up evaluation in the event of adverse reactions, or failure of any treatment regimen. Dispensing or prescribing a prescription product also requires a VCPR.
The AVMA medical record requirements also indicate that veterinarians must comply with standards established by state and federal law. In Alabama, Part 930-X-1 of the Alabama Administrative Code authored by the Alabama State Board of Veterinary Medical Examiners, sets forth minimum recordkeeping requirements for veterinary facilities and mobile premises. These requirements are the minimum standards, and are very basic, including keeping records in accurate, timely, and legible fashion, and identifying the patient's problems and condition. Records must be kept for a minimum of three years following the last office visit or discharge of the patient, and according to the AVMA requirements, are the property of the practice and the practice owner.
Clients who request records must be given copies or summaries. Such records are considered privileged and confidential, and generally may not be disclosed to third parties without the client’s consent or court order. Original records must be retained by the practice for the statutory period.
In addition to AVMA and state requirements, there are Drug Enforcement Administration recordkeeping requirements for controlled substances. The Food and Drug Administration recordkeeping requirements may apply to animal drugs, feeds and food, and devices, and for certain food supply safety issues. U.S. Department of Agriculture requirements may also apply with respect to veterinary biologics, and drugs for food-producing animals, and related withdrawal periods.
Keeping required documentation and records in good order minimizes legal risk associated with the practice of veterinary medicine. Well-kept records reduce the risk of miscommunications with clients, errors in records, incomplete records, noncompliance, and possible claims of negligence or malpractice. Memories fade, and people forget what happens in a rush, or in an emotional situation. Proper documentation will minimize or eliminate "he said-she said" controversies arising in such situations.
Key recordkeeping "hotspots" include:
§ making records contemporaneous with observations and treatment;
§ treatments and diagnostics offered, and the basis for each;
§ client decisions to NOT follow recommendations;
§ phone conversations regarding treatment;
§ informed consent in writing to procedures (with a witness), particularly if expensive or high risk;
§ entries made in periods of absence or vacation; and
§ instructions regarding drugs for food-producing animals with withdrawal periods.
To help make recordkeeping more routine and efficient, a practice should consider using commercially-available software and systems, commercial or customized stamps, stick on labels, and preprinted medical forms to minimize the repetitious part of recordkeeping. Those in the practice should use customized or standard medical abbreviations. The staff should be trained to help with recordkeeping and each entry should be initialed by the individual making the entry.
Good recordkeeping does a great deal to help a practice avoid legal claims related to noncompliance with governmental requirements, as well as protect a practice from malpractice or negligence claims. However, ultimately, excellent medical recordkeeping should not be to simply prevent lawsuits, or meet veterinary medical board requirements; it should be done to provide optimum patient/herd care and/or a safe food supply.