It hasn’t hit the mainstream media yet, but veterinarians across the state have discovered a quantum defect in the space-time continuum, that allows hours and hours of their hard labor to almost magically disappear. It’s a little known phenomenon called the Medical Record Quantum Singularity.
How you say? The old adage holds true, “if it isn’t written down, it didn’t happen.” As an example a medical record entry might be solely: “PE – WNL”. In our busy practices with a healthy “well pet” exam, we might be tempted to make such sparse notations. What isn’t recorded is any “data, including that obtained by instrumentation, from the physical exam” [CCR §2032.3 (a)(7)] which is required by law.
While the statute does not specify what must be included in the medical record, we use the “standard of care” in the community to determine when a record falls short. That community is the entire State of California; both rural and city, veterinarians are held to the same standard.
It’s not only the law, it’s for your own protection. When the VMB reviews a record that states “PE – WNL” the presumption is that essentially no physical examination took place. Certainly, the eyes and ears weren’t examined. The teeth weren’t examined. The heart and lungs were not assessed. The abdominal palpation isn’t described. “But I did do a thorough exam, I’m just too busy to write all that down!” Was a neurological exam performed? How about a fundic exam? Tonometry? Blood pressure? Those all might be considered part of a complete physical exam in some practices.
There are many examples of “complete” medical records too. Some use a sticker with check boxes for the major systems. Some use a pre-printed physical exam page, with fill-in and check boxes. The important key is to note normals, abnormals AND not examined. If there is a check box for “neurological exam” and you don’t do a complete neuro exam, you should indicate it was not performed, not that it was “normal.” You could also note simply: "The patient appears to ambulate normally."
Can you actually diagnose a patient if you haven’t interviewed the client for a history? Not unless our patients suddenly learn to talk. The pet owner is a source of invaluable information on our patients. Do you think a pediatrician would treat a toddler without asking the parents for the history? And that history must be recorded, or it’s as if the conversation never happened.
Each entry for each visit should include a system by system evaluation of both abnormal AND normal findings. That’s the only legitimate way to arrive at an assessment. And then on to a treatment plan. All of which must also be documented in the medical record.
One of the items often skipped is client education. You might have pre-printed handouts, or spend 30 minutes educating the client on home care. But if it’s not documented, it didn’t really happen. When the client complains you didn’t warn them against letting their recently spayed dog go with the dog walker to the beach for 2 hours, your “Routine OVH” notation before discharge won’t protect you.
Don’t let yourself be the victim of the Medical Record Black Hole. Document the history. Document each aspect of the physical exam. Actually write out your assessment and treatment plan.
Include your recommendations and home care instructions. Include follow up contact and telephone consultations with the client.
Ask yourself, “Can another veterinarian, not familiar with my practice, easily understand my medical records and continue care of the patient?”
This article was originally published in the Winter 2004 Newsletter of the California Veterinary Medical Board. It is reprinted here by permission of the author.