Mind the three Rs: recall, recheck or remind
The usual encounter starts with a progress-notes entry for the client concern, a weight (hopefully sequential with a body-condition score), a TPR, a BP, lead II ECG, tonopen screen and maybe even a urinary kidney screen. A 12-system physical exam should be recorded with notations of either normal or abnormal.
This process is called a physical exam at entry, and is critical for each consultation encounter.
Now it starts getting tricky. Since our ambulatory medicine heritage calls for quick empirical treatments at the lowest cost; our companion animal medical knowledge is based on the fact that 89 percent of all pet owners give their companion animal's family status, and a third of those give them child status. These are true pet parents, and they want "peace of mind," not low-bid healthcare. (When was the last time you sought a personal cardiologist or OB/GYN specialist by low bid?) In fact, reputable companion animal diagnosticians on outpatient duty actually average 40 percent-plus day-time admissions for diagnostic work-ups. What is your rate?
After the history (subjective) and exam (objective), the problem-oriented medical-record documentation process is supposed to stop for an assessment summary. It is an essential component for the next provider. For some unknown reason, most veterinarians seem to stop caring about their colleagues early after graduation from veterinary school, and their medical records reflect this neglect. Some of the computer systems on the market today are incorporating progress notes ... and it is magic in the making. It leaves a healthcare audit trail from single-entry documentation.
Regardless of your system, unresolved issues and atypical findings, including deferred or empirical/symptomatic care, must be entered into the master problem list. The next step is to ensure every item on the master problem list is assigned at least one of the three Rs (recall, recheck or remind).
The operational premise is that no patient leaves any practice without being assigned at least one of the three Rs. Concurrently, each of the three Rs is linked to an attending nurse (70-80 percent of the cases) or the attending doctor (about 20-30 percent of the cases are in some form of treatment-plan transition and required an in-process doctor's assessment).
For more discussion of documentation formats, please review the VPC Signature Series® monograph, Medical Records for Quality & Continuity of Care.