by Cherie T. Buisson, DVM, CHPV
Certified Hospice and Palliative Care Veterinarian

Originally published on DrAndyRoark.com

I’ve been in practice for 15 years now. I’ve seen a lot of things that upset me. One of the things that turn every day into “Throat Punch Thursday” is when clients bring me receipts posing as medical records. Today, I had a complicated geriatric feline case come into the hospital with a half page long medical record that told me nothing. We called both clinics where the cat had been seen asking for full medical records. Nothing. We called and asked if we could just (for the love of all that is decent and holy) have the cat’s weight and find out if the vet had heard a heart murmur. They said they’d have to call us back.  After over an hour, we managed to get two weights from one clinic.  The other said they didn’t see where the cat’s heart had been auscultated or a weight had been recorded, but he did have vaccinations.  *FACEPALM*

We’re all colleagues here.  We all know that the reason we keep medical records is, so we have vital information. That information needs to be shared upon request, the very first time it’s requested.  Withholding information could result in harm and is inexcusable.

This is all about the patient. We are professionally obligated to share our thoughts and findings with a patient’s veterinarian if the owner requests that we do so. Most of the problem likely lies with our training of the reception staff. We let them figure out how to use our office software and never ask them about how they handle medical records. We don’t explain the importance of prompt delivery of medical records and what they should contain.  We need to make it clear that medical records are vital to patient health, because a pet may be dying on another vet’s exam table while our team wastes time sending receipts for flea prevention and boarding. All of us have requested medical records at one time or another. We should send what we would want sent to us. It’s that simple.

For those of us paranoid souls who require that we “look over” the records before sending them, we need to consider writing our records as though we expect them to be read. It’s illegal to alter past records, so I’m not sure what the “look over” is going to do for us. The receiving veterinarian is not the Board of Veterinary Medicine or a lawyer (usually). The records don’t need to be perfect.  That vet just needs to know if an injection of NSAIDS is inappropriate because we already gave one. They need to know if the lab work they want to run is already complete. We should keep all notes about client communication professional and accurate so that we’re not worried if they see what we’ve written.

If we aren’t proud of our records, we need to change them.  Weight, TPR, exam/lab/x-ray findings, assessment and plan. BOOM.  That’s what we all need. That’s what our patient deserves to have so he or she can receive a thorough workup from a colleague. Remember how they taught us in school that the history is the most important part of the examination?  We are the history. Clients don’t remember accurately everything about the visit they had a year ago. It’s up to us to make sure we communicate what happened properly.

I know clients often don’t give us any notice when switching practices. I know it’s a pain when you get that call, and someone needs records right now. I’m in the same boat several times a week.  I get it. I hate when clients leave me, too. I hate it when someone else’s bad planning becomes my emergency. I really, really hate it when it takes days to get a medical record, and when it finally arrives, it’s a receipt for cat nip toys and Pill Pockets.

When I’m back at work next week, I promise I’m going to ask the receptionists what they send when a client requests medical records. I’m going to make sure that what they send is…….everything! Will you make that promise? The life of a patient could depend on it.