There are dozens of medical record-keeping software systems in use throughout the veterinary industry. And for each individual system there are dozens of methods and versions of utilization specific to each clinic. The veterinary industry, like most other health care professions, has yet to find a uniform method for recording medical treatment and recommendations.
Your ability to interpret previous medical records, institute necessary treatment, and leave records that ensure continuity of care is an indispensable trait in a relief veterinarian and one that’s not as simple as it might seem.
Be aware that as a relief professional, your records leave a lasting and legal representation of your work. You may never be notified if one of the cases you see on a relief shift goes to court. Your medical care, recommendations and your decision-making process are likely to be only represented by your SOAP notes.
Below are a few “FYIs” that might make dealing with record-keeping in a new clinic a bit less stressful.
Keep your cool
It is really, really easy to become frustrated with the veterinarian who leaves you with chicken-scrawl, handwritten records or records that are incomplete or non-existent for the complicated case that’s scheduled for a 10-minute follow-up as your first appointment of the day. This happens…a lot.
It is not helpful to loose your cool. Yes, it is very justified…yes, they’re wrong…yes, you are right…but getting upset doesn’t solve the problem. And it is ESPECIALLY not okay to loose your cool in front of the hospital staff. No matter what your opinion of Dr. So-and-So is, in their opinion, he/she might be the best veterinarian on the planet and incapable of error. Don’t compromise your professionalism and newly-acquired reputation in this clinic by derogatory comments.
You can’t fix poor organization or a faulty system. Many of us are of an organized, type-A personality, and the practice you’re working in and the veterinarian you’re filling in for may not be made from the same mold. It is not your responsibility to judge the adequacy or format of the clinic’s records or try to make improvements. Your only responsibility is making sure that any record pertaining to YOU is impeccable and complete.
Play by their rules
Along the lines of the previous point, you were not brought into the clinic as a consultant on their medical record-keeping system. Any suggestions or comments you make, especially during a short, 1-2 day relief shift, are unlikely to be welcome.
Make sure that your records are “in kind” with the clinic’s existing system.
Records made outside of or differently than the normal system will be lost and continuity of care for that patient compromised.
Be prepared for diversity
As mentioned above, there is an enormous array of veterinary medical record-keeping software systems from solely paper-based to completely paperless. There is an equally mind-boggling number of ways to implement these systems.
It is not your responsibility to be familiar with each and every record-keeping system and their variations. It is helpful if you have a basic familiarity with a program database or format, but always ask for a walk-through before your start on day 1. This clinic’s utilization may be very different from anything you’ve worked with previously.
Make sure you get an overview that, at minimum, includes a “how-to” of the following:
Don’t hesitate to ask for help in looking up records or entering your own – it is more important to keep complete, consistent records. Ideally, you have a technician assigned to you who can be a constant source of “how-to” answers. It is customary to have the technical staff enter estimate, charges, routine reminders, and other administrative data entry. While there is always the exception, most clinics will utilize this routine.
One area that may differ significantly between clinics is whether the doctor or technician goes over the estimate with the client. In an unfamiliar clinic, it is more time-efficient for a technician to go over the estimate with the owners. Pricing questions that arise are better answered by the technician who is familiar with the clinic’s practices. Make yourself available to answer questions or comment on the treatment plan if necessary.
Clear and concise
Be meticulous in your record keeping. Your protocols may be slightly different from the practitioner you are replacing – make sure they can follow your assessment and treatment plan easily.
Leave clear and obvious follow-ups for the practitioner you are replacing so that when they return, it is clear which patients need to be called or additional treatments performed. Rounding with the lead technician or another veterinarian at the end of the day about pending follow-ups or critical cases can help prevent cases from falling through the cracks.
When dealing with paper records, take extra care to ensure that your handwriting is legible. If you are accustomed to typing your records, you may find that writing your physical exam findings slows you down dramatically. To ameliorate this problem, consider ordering a supply of physical exam labels to affix to the records. This will save you time, prevent hand cramps, and make sure the physical exam is thoroughly documented in each record!
Too many passwords!
Decide in advance how you will handle passwords at the various clinics you work. Juggling multiple passwords is a headache as well as a security risk for both you and the clinic. If you are okay with having multiple passwords, make sure you choose secure passwords and protect them carefully.
You will likely need to maintain a lot of flexibility around this issue. Each clinic will have its own protocol and security preferences. However, if offered the choice, it is the author’s opinion that utilizing the login information for the technician assigned to you is the easiest solution. That technician will be entering the estimates and charges for the day and will best know the circumstances around a particular case if there is a question in the future. Additionally, as a relief veterinarian, there is no need for you to have additional administrative authority beyond that of your technician.
Remember to date and timestamp all your records as well as sign or type your name and title into each of your record entries since the computer will track the technician’s information and not yours if you are utilizing a computer-based record system.
In the words of a colleague:
“It’s not easy being a good DVM when one works full-time and it’s certainly even more challenging as a relief veterinarian to do a great job while juggling new staff, different protocols, a new computer system (ugh!), etc; and still have the time and sanity to complete detailed, accurate, and legible medical records at the end of a long day…”
- Laura C., Colorado
It takes time to develop record-keeping skills that meet your high standards while still being flexible enough to adapt to whatever clinic scenario in which you find yourself.
Casara Andre, DVM, cVMA
Scheduled Relief, Founder