Setting your (medical) records straight

  |   Practice Management

If you have been practicing in Washington for several years, it is a good bet you have not reviewed the Practice Act since your initial licensing. It is important to remember, however, that the rules do periodically change. You should include a review of the Practice Act in your continuing education plans every few years to avoid inadvertent violations. Since the “Act” is not a thrilling read, I thought I would try to provide a more palatable review of the section generating the most violations.

WAC 246-933-320 (7) deals with records. While the old vinyl type has made a bit of a comeback, our litigious society is ensuring a healthy future for the medical variety. By Washington law, every veterinarian must keep daily written records of all animals treated. Simple enough, but just remember “The Act” now mandates that they must be legible.

Record rules apply to all private-practice veterinarians regardless of the type of practice. However, records for food and fiber producing animals, those kept in herds or flocks, do not have to identify each individual animal. These records may be organized by hard/flock under the individual client. The records of companion animal litters that are under three months of age and not yet permanently placed may be kept on a single record for the litter on the mother’s record.

The following list of standard information must be on each medical record:

  1. Owner information – name, address, phone number
  2. Identification of the animal or group – name or number
  3. Description of the individual animal (or as applicable for group) – species, breed, age, weight, color
  4. Record of immunizations
  5. Beginning and ending dates of custody
  6. If applicable (limited service shelters for example) – documentation of low-income status of owner

Furthermore, the following additional information showing reason for care and justification for treatment is required:

  1. History of the animal’s condition as it pertains to its medical status.
  2. Physical exam findings, recommended diagnostic tests and performed diagnostic tests with results.
  3. Provisional or final diagnosis
  4. Any treatment administered, performed or recommended.

In terms of treatment, the following must be documented in the record:

  1. Names, dosage, route, and amount of any medication administered or prescribed including anesthetic agents
  2. Description of any surgery performed
  3. Progress of the patient

It is also highly recommended, but not legally required, to note down any declined treatments. The simple phrase, “Recommended                 , owner declined,” starves lawyers.

All medical records must be kept for a minimum of three years after the last time the animal was examined or treated, although the WSVMA recommends eight years to help protect you in the event of legal action. Your liability insurance may have other requirements. If a client requests a copy of their records, a copy must be available within 10 working days of the request. However, by law, the records must be “available as promptly as required under the circumstances.” Keep in mind that failure of the client to pay for services is not a defensible reason to withhold copies of medical records. Unnecessary delays of pertinent medical records in an emergency may be a violation. Veterinarians may charge the client a reasonable fee for copies of the records.

Radiographs and other medical images are part of the medical record and belong to the facility that prepared them. When authorized by the pet’s owner, the radiographs must be released to other veterinarians. Upon request from the originating facility they must be returned by the “borrowing” facility within 10 working days. If the originating veterinarian provides a copy of the medical image, he or she may charge the actual costs of duplicating the medical image.

Remember, no practitioner relishes record keeping. It is a time consuming activity that generates no glory or revenue, but beyond good medicine, it is your best defense against legal action.

To access Washington Administrative Code 246-933-320(7), click here.

By Linda Crider, DVM

Posted November 3, 2017