How to keep meticulous medical records

How to keep meticulous medical records

It's difficult to document everything in a medical record and even more difficult to know who should do it and when. Cut out the guesswork with these guidelines.
Sep 30, 2009

Medical records play an integral part in client and pet care. They're primarily intended to benefit patients by recording the care recommended and provided. They also serve as legal documents in court. So it's important to keep records accurate and up-to-date. But just who needs to log what when? Here's the answer—regardless of whether your practice is paperless or paper-heavy.

What: Client and patient details (name, mail and e-mail address, phone numbers; pet name, reason for visit, species, breed, age, gender, reproductive status, color, distinguishing markings, microchip)

Who: Receptionist

When: For new clients, collect all this information when they initially schedule appointments, then confirm it when they arrive. Verify existing clients' contact information when they schedule a visit, and, if they make their next appointment before leaving the practice, double-check their contact information before they head out.

Why: Clients appreciate when you greet them and their pets by name. For drop-off or hospitalized patients, you must collect owners' information in case you need to contact them for an emergency, and doing so as soon as clients walk in the door ensures you remember. An accurate address is essential for billing purposes as well as for follow-up contacts, such as reminders. Patient details also allow veterinarians to prepare and, later, help ensure appropriate treatment.