Last week, a client came into my office for a second opinion on her dog that another veterinarian treated for a presumed cardiac
problem. I knew the initial attending veterinarian and was familiar with her practice. She was an old-timer—someone who'd
been in the field a long time and still followed the loose prescribing and recordkeeping practices of days gone by.
For example, the package of diuretic the client brought in for me to see was labeled "diuretic"—useful information if a little
kid spotted the unsealed envelope and mistook the contents for Skittles. Sometime later we got a copy of the medical record
for that case, and that's when I knew the condition might be really serious: The diagnosis was "bad heart."
Why it's critical to document
Those of us old enough to remember the TV series Gunsmoke know that in the 19th century medical records weren't all that important. Old Doc took an untold number of bullets out of
various parts of Marshal Dillon's body and never wrote down a thing. There were two reasons for that: Doc remembered everything
he ever treated his patients for because he had taken care of them since birth. Equally important: Dodge City's only law office
was so busy handling the marshal's criminal cases it didn't have time for malpractice cases against Old Doc.
Fast-forward to today's world of widespread medical testing and case referrals, and it's easy to see why documentation is
key. So much happens during a veterinarian's relationship with a pet that it's impossible for a veterinarian to remember all
the details of a single patient's history. That means quality and thoroughness in recordkeeping are crucial for medical purposes.
Details about observations and noteworthy history help the attending veterinarian as he sifts through subsequent lab work
and imaging reports. Content created at the beginning of a case is also critical for referral veterinarians who come into
the case later. Lost or undocumented thoughts and observations by the original veterinarian can never be retrieved or re-invented.
Specialists who come into the picture after a clinician's initial exam, no matter how skilled, will never be privy to what
could be seen at the beginning of the case. Therefore, it is incumbent on all doctors to be thorough in their examination
and just as thorough in their documentation of that exam.
The role of medical records today
Why do veterinary law experts make such a big deal about complete and detailed medical records? From a legal standpoint, nothing
is more vital than what those records fail to contain. When a medical record is introduced into evidence in a state veterinary
board or civil veterinary malpractice case, it's likely that lawyers experienced in spotting medical and surgical indiscretions
and experts in the veterinary profession will scrutinize it. These analysts have the benefit of 20/20 hindsight. They already
know the dog's vascular malformation was the identified illness or the cat's owner had secretly treated it with ibuprofen
prior to its arrival at the clinic.
This allows the plaintiff's team to reverse-engineer the diagnostic and treatment protocol of the doctor initially treating
the case. Any diagnostic or case management oversight becomes a glaring omission in the eyes of a cadre of armchair quarterbacks.