Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September
You have all likely heard the adage perpetuated by Plaintiff’s attorneys that, “If it’s not in the medical record, it didn’t happen.” Certainly, you cannot be expected to memorialize absolutely everything that is said and done during an appointment. However, well documented medical care is not only beneficial to the patient and their owners, but to you and your practice should you ever be placed in the position of having to defend that care. The medical record is very often helpful, especially where memories have faded and the only recollection of the event is the written record.
Regardless of all the benefits of a well-documented medical record, it is also a requirement and condition of Florida statutes and administrative codes, and the retention of your license. Florida Statutes require that, “Each person who provides veterinary medical services shall maintain medical records, as established by rule.”1 Though Florida Statutes do not go into greater specificity about what should be included in the medical record, Florida Administrative Code for the Board of Veterinary Medicine provides specific guidelines for the creation and content of medical records.2 Florida Administrative Code requires that the medical record be created, “as treatment is provided or within 24 hours from the time of treatment.”3 It goes on to state that the medical record shall include:
Date of each service performed
Name of owner
Patient identification
Record of any vaccinations administered
Complaint or reason for services
History
Physical exam including weight, temperature, pulse and respiration
Any present illness or injury
Provisional diagnosis
The primary purpose of the medical record is to communicate the condition of the patient at the time of their examination or treatment. It serves to document what you have done and why. Inversely, it also serves to document what you have not done and in some circumstances, why you have chosen not to do so. Therefore, the medical record corroborates your actions, thought process and decision making with respect to your care of the patient. The patient’s history is also relevant, especially where different veterinarians within the practice will be seeing the animal, so that each veterinarian is fully informed of the patient’s condition in one accessible place and optimal care can be provided. Remember as well that patients may leave your practice and therefore, your medical record becomes important to the continuity of care provided by subsequent treating veterinarians. Depending on the number of patients seen in the day and the requirements of your practice, it may be difficult to complete your documentation contemporaneous with your care or within 24 hours. Contemporaneous documentation is so important, however, that Florida Statutes4 allows disciplinary action for the failure to do so, and Florida Administrative Code allows for the issuance of a reprimand, up to one year of probation, and a fine of up to $2,000 for the failure keep contemporaneously written medical records.5 Therefore, it is advisable that you make every effort to document as much as is reasonably possible as soon as is reasonably possible. In addition, Florida Administrative Code also requires that if the following services are provided, they shall also be documented in the medical record6:Laboratory reports
Radiographic studies
Consultation
Medical or surgical treatment
Hospitalization
Medications prescribed or administered
Pathology reports
Necropsy findings
Note that this section of the Florida Administrative Code deals primarily with the actions taken by the veterinarian after having assessed and examined the patient. Though the mere decision to perform these tests, administer medications, or perform surgery speaks to your thought process, it remains beneficial to document your reasoning. These tests, medications and procedures are very often where a majority of costs to the client are incurred and the ability to explain and justify their performance can become an issue should billing be brought into question. One of the key components of this medical record documentation, and which is frequently the cause of adverse incidents, is medication administration. Medication is a critical component of the record and often takes the place of other treatments or is the primary treatment before other procedures are explored. It is also advisable to document by whom the medication was ordered, administered and dispensed, as well as the route, strength and dosage of the medication. It is of such critical importance, that the failure to appropriately document medication administration can also lead to disciplinary action pursuant to Florida Statutes and Florida Administrative Code. Florida Statutes allow disciplinary action for failure to document the, “…storing, labeling, selling, dispensing, prescribing and administering of controlled substances.”7 Sanctions can include an administrative fine from $1,500 to $5,000, and up to two years probation.8 Though not required by statute or administrative code, client communications are an essential component of the medical record. Because so much of the care provided to animals is an option presented to the client, you should ensure that the treatment plan, recommendations for tests and procedures, the client’s agreement with or refusal of, and the possible consequences of these decisions be documented. A client’s recollection can at times be clouded by their emotional involvement in the outcome. The medical record, therefore, can provide a factual recitation of the offers presented and the risks, benefits and costs associated with these. Florida Statutes do provide for disciplinary action when, “Performing or prescribing unnecessary or unauthorized treatment.”9 For that reason, documentation of the need for treatment and the client’s authorization may also serve to protect the veterinary provider from disciplinary action. Further, some clients may be non-compliant with the care of their animals and treatment is rendered ineffective. It is recommended that this also be documented so that in the event of an undesired outcome the veterinarian can refer to their good care and recommendations. Significant complications, adverse incident or unexpected outcome should also be disclosed to the client as timely as possible. A good guideline is to make disclosure if the incident is material to the care, the client has required another procedure or additional care as a result, and certainly if they have suffered a serious injury. Medical record documentation of such an incident is not required by statute or code, but depending on your institution or practice, you may be required to document disclosure of the incident in the medical record. This need only be a brief summary of when the disclosure was made, to whom it was made and a factual recitation of the event free of speculation. Do not criticize other healthcare providers as the medical record is not a vehicle for assigning blame. When in doubt, call your malpractice insurer for advice and guidance on whether disclosure needs to be made and how to appropriately accomplish that. Florida requires veterinarians to retain medical records for a minimum of three years after the last patient treatment entry, terminated their practice or relocated their practice.10 In the event of the veterinarian’s death, their executor should retain the records for two years from the date of their death.11 Though certainly good guidelines, your particular facility or practice may have more specific guidelines you are required to follow. You should also consider the statute of limitations, whether there were significant complications with the care of the animal, and whether there existed a contentious relationship with the owner, in determining how long to keep particular records as having these available is a vital part of the defense of any malpractice action. In Florida, records are confidential and may not be furnished to any person other than the client, his or her legal representative or other veterinarians involved in the care or treatment of the patient, without written authorization.12 Several exceptions exist, including exceptions for a subpoena from a court of competent jurisdiction with proper notice, statistical and scientific research (provided the information is de-identified), a medical negligence action or administrative proceeding, disciplinary actions against veterinarians, and suspected animal cruelty.13 The importance of medical records cannot be overstated. Medical records not only provide the veterinarian with an outlet to document the care provided, but also encourages continuity of care within the practice and with other veterinarians if necessary. Within the context of a possible claim or litigation, they are of tantamount importance to the defense of good veterinary care. Words have power. When those words are used concisely and thoughtfully in the medical record they have the ability to deliver optimal care to the patient and afford the veterinarian a great deal of protection. In the final segment of this article, we will discuss veterinary malpractice litigation. 1.474.2165(2) Fla. Stat. (2013) 2. Fla. Admin. Code R. 61G18-18.002 3. Fla. Admin. Code R. 61G18-18.002(3) 4. 474.214(ee) Fla. Stat. (2013); .474.214(2) 5. Fla. Admin. Code R. 61G18-30.001(ee) 6. Fla. Admin. Code R. 61G18-18.002(4) 7. 474.214(1)(mm) Fla. Stat. (2013); .474.214(2) 8. Fla. Admin. Code R. 61G18-30.001(mm) 9. 474.214(1)(l) Fla. Stat. (2013) 10 Fla. Admin. Code R. 61G18-18.0015(1) 11. Fla. Admin. Code R. 61G18-18.001 12. 474.2165(4) 13. Id.
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