A medical record can be the first, and best, line of defense for a veterinarian facing a malpractice claim—but only if the record is complete and accurate. An animal’s veterinary medical record, as the name implies, is a complete history of the patient’s clinic visits or field calls, examinations, diagnoses and treatments. The record is an archive of the animal’s veterinary care in the past, a road map for care in the future, a guide for accurate client billing and an important communication tool to prevent misunderstandings between veterinarians and their clients.
Less obvious, but equally important, a medical record can be the first, and best, line of defense for a veterinarian facing a malpractice claim—but only if the record is complete and accurate.
Steven Sedrish, DVM, from Upstate Equine Medical Center in Schuylerville, New York, discussed the importance of a legally defensible medical record, and how to create one, at the American Association of Equine Practitioners 59th Annual Convention on Dec. 7-11, 2013.
“Any medical record can wind up in court,” Sedrish said, “and a single mistake...