There are so many reasons to keep good veterinary medical records, said Cynthia MacKenzie, DVM, a Trust veterinarian with the AVMA PLIT. Those reasons include medical, legal, ethical and regulatory necessity.
MacKenzie said the Trust has reviewed veterinary claims since the 1960s and continues to monitor them. She said there has been a steep rise in professional liability and license defense claims in recent years. This highlights the need to keep good medical records.
“When I teased out the equine numbers, equine is up 15% year-over-year in just professional liability claims,” she said. “Veterinarians are under attack for their medical records from licensing boards. The expectations from owners have increased. We really want to highlight the need to keep good medical records to defend yourself if you ever need to.”
Medical Reasons for Keeping Good Veterinary Medical Records
When we look at the medical reasons for keeping good medical records, it’s really to document the patient condition and medical care, said MacKenzie. “But it’s also there to document your standard of care.
“A good rule to follow is that any veterinarian who reads your records should be able to understand the horse’s condition and pick up where you left off with treatment of that horse,” she explained.
MacKenzie discussed items that should be contained in the medical records of each patient.
Legal Reasons for Keeping Good Veterinary Medical Records
Veterinarians should know their states’ practice acts. The practice act is the law under which you are granted a license to practice veterinary medicine.
Practice acts have certain requirements for recordkeeping, like how long you should maintain medical records, said MacKenzie.
“Focus in on looking at your practice act as guidance,” advised MacKenzie. “If you haven’t picked up a copy and looked at it recently, I highly recommend that you do so.”
MacKenzie stressed that records are your defense. “They are crucial in the defense of malpractice lawsuits and license or board complaints,” she said.
“We read a lot of claims that are he said, she said,” MacKenzie stressed. “The client said this, and the veterinarian said that. It’s nice if the communication is documented in the medical record so we can get rid of allegations of negligence or get rid of those ‘he said, she said’ situations. Those need to be accurate, legible, and timely.”
She said the rule of thumb with attorneys and boards is that if it was not recorded in the medical record, it was not performed.
Regulatory Reasons for Keeping Good Veterinary Medical Records
In the veterinary space, there are many reasons veterinarians need to be in compliance with the regulatory aspects of practice.
MacKenzie discussed state, DEA, regulatory, organizational (such as AQHA and FEI) and other implications of recordkeeping.
Ethical Reasons for Keeping Good Veterinary Medical Records
AAEP has had a focus on this recently, including a recent webinar in which MacKenzie was one of the presenters. She noted that the AVMA principles of veterinary ethics includes language about medical records.
“As I review medical claims, equine practitioners have some of the worst medical records,” said MacKenzie. “They are lacking documentation. And if we get documentation, a lot of time it is just invoices. And invoices are not a medical record.”
Other Reasons for Keeping Good Veterinary Medical Records
Keeping good records is also part of excellent customer service.
Good records can also be a rich source of data for trends in your practice and for research purposes.
Best Practice Tips
MacKenzie said she has what she calls the Three T’s for best practice tips—templates, technology and technicians.
Templates are excellent ways to have efficient and accurate medical records.
Technology is important, particularly for mobile practitioners. Look at voice dictation systems to capture items to go in medical records.
Technicians are important. “We have had a tremendous focus in recent years on how to use technicians,” said MacKenzie. “Using them for medical records is powerful in the hospital and in the field.
“I think they are the secret weapon to both efficiency and effectiveness, and that comes into play with recordkeeping.”
One final best practice tip for keeping good veterinary medical records: Review your practice act. “There are changes constantly being made to practice acts,” advised MacKenzie. “For example, the Texas Board of Veterinary Medical Examiners recently adopted a new version of its patient recordkeeping rule that took effect in August of this year.”
MacKenzie advised that if you practice in multiple states, the recommendation is that your records adhere to the state with the most stringent requirements. That way you will achieve compliance.
MacKenzie’s final take-home message was: Document, document, document.
“If ever required, make sure your records will defend you,” she stressed.
Don’t miss MacKenzie’s abstract of her talk at the 2022 AAEP Convention titled Review of Good Record Keeping: Will Your Documentation Defend You? in the 2022 AAEP Proceedings or watch her presentation on-demand if you were registered for the Convention.
We also invite you to listen to MacKenzie in an earlier podcast on Avoiding Malpractice Complaints.
About Dr. MacKenzie
Dr. Cynthia MacKenzie joined the AVMA Trust staff in November 2017. She represents the Trust around the country and works with veterinarians and veterinary students to raise awareness of insurance offerings and risk management solutions.
MacKenzie is also a certified Insights Practitioner and enjoys delivering Insights sessions to help people develop their self-awareness skill and understand their unique strengths.
Prior to joining the Trust, MacKenzie was employed at Luitpold Animal Health as a Technical Services Veterinarian and Merck Animal Health as a Senior Technical Services Veterinarian and an Associate Director of Learning and Development. While at Merck, MacKenzie co-founded the Unwanted Horse Veterinary Relief campaign that provides vaccines to qualifying equine rescues.
Prior to her industry roles, MacKenzie worked in private practice in San Juan Capistrano, California, and Lexington, Kentucky.
MacKenzie received her Doctor of Veterinary Medicine and Bachelor of Science from Texas A&M University and holds active memberships with the American Veterinary Medical Association (AVMA), American Association of Equine Practitioners (AAEP) and Christian Veterinary Mission (CVM). As part of CVM, MacKenzie has participated in numerous trips to Nicaragua to teach sustainable agriculture and veterinary education to health care promoters in remote areas of the country.
She has also published in the Journal of American Veterinary Medical Association, the American Association of Equine Practitioners (AAEP) Proceedings and Current Therapy in Equine Medicine, Edition 5.
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