Documentation first step to increase client compliance

Documentation first step to increase client compliance

Nov 26, 2003

When a pet's physical exam is completed, the findings are recorded in the pet's record. Now, another person reading the record can see the findings.

Okay, but say that you make a recommendation to an owner that the pet needs to change foods, but you don't write this recommendation down in the pet's record. Did it really happen? We have to assume that it did not. There is no way to prove that the recommendation was or was not given to the client. How can you expect to follow-up on client compliance?

Any recommendation given to a client should be well documented. It also should be documented if the client accepts or declines the recommendation. When clients accept a recommendation there should be a follow-up on how the pet is progressing. The follow-up could be a phone call from the technician to ask how the transition is going or a client relation specialist's call to schedule a recheck exam. All conversations need to be documented in the patient record and initialed. At our clinic we also write in the chart the date and time that a progress exam is scheduled. This is a way to evaluate a client's "noncompliance" or compliance.

For example, a client calls back four months later and the pet has an ear infection that "the doctor didn't fix the last time" (and they didn't come in for the recommended recheck), "Why do I have to come back in when I know it's the same thing?"

Being specific in a record will also save you time, money and aggravation later. If a clear recommendation is written in the chart another team member does not need to track you down to find out what you meant or wanted. This also sends a subliminal message to the client that you did care about their pet and believed in your recommendation because you cared enough to write it down.

What if the writer has illegible handwriting? For the more common recommendations try using stamps. How many times have you received a record from another practice and you have no idea what vaccinations were given? Our practice took all the vaccines and had ink stamps made up with the common abbreviation (Feline Leukemia = FeLV), (combining the stamps with the vaccine labels in the written charts makes for a complete record.) All the doctor or technician needs to do is stamp the chart with the appropriate vaccine. Now anyone can see what was given and on what date. If you can't change the way you write, then try to change what you write. Be more specific. Recommending weight loss is good but recommending weight loss with a specific diet is better.

For those practices that are paperless, check with your software provider on ways to create codes for recommendations. My experience has shown that most can walk you through how to set up "bundles" of items or codes for recommendations.

Better record keeping does not necessarily mean you need to write more but it does mean if it happens, it should be recorded in the patient's record and initialed.