Create airtight medical records

Create airtight medical records

Apr 01, 2008

Q. We have problems keeping accurate records. How can we maintain proper records?

Christine Merle
"Detailed and well-documented records are key to preventing malpractice claims," says Christine Merle, DVM, MBA, CVPM, a practice management consultant with Brakke Consulting in Dallas. "Every chart should be maintained as if a jury would read it."

Your records should contain this information:

  • Reason for the appointment
  • Specific physical exam findings
  • Any recommended, performed, and refused diagnostics
  • Diagnosis
  • Treatment options presented to and chosen by the client
  • Plan for future care
  • Names of team members and doctors involved with the client's appointment
  • Any additional information your professional liability insurance provider and state veterinary licensing board require

Next, review records from the last few months and ask these questions:
  • What, if any, information is missing?
  • Who, if anyone, leaves records incomplete?
  • Is there a tool, such as a sticker, computer template, or form, that will help complete our records?

Then conduct monthly record reviews with your team. You can make the review process fun by holding mock court trials or giving "Can you read my handwriting?" quizzes, Dr. Merle says.

"Good medical records mean good medicine, and good medicine is what clients expect—and pay for—at your practice," she says.