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Protect pets (and yourself) with solid veterinary records
Don't let careless omissions or missed rule-outs stand in the way of thorough documentation.


Missing rule-outs spell trouble

Sometimes there's a tendency, especially among experienced practitioners, to itemize only a short rule-out list in the medical records. While other causes of the presenting problem might be in the back of a veterinarian's mind, it's sometimes easier to mention only the most likely causes of a medical problem while awaiting blood work and other diagnostics.

The absence of a complete or fully brainstormed initial rule-out list implies to later record readers that consideration of the case was incomplete or superficial. While the thought of anyone critically reviewing a doctor's work may seem unfair, it's important to recall that malpractice trials are about obtaining money damages, not about objective analysis of a veterinarian's clinical capabilities.

It's not the client's responsilbility

I just got two identical certified letters from my dermatologist. He wants me back to check for more pre-cancerous spots on my shoulder like the one he removed last fall. Now does he just want to scare me into coming in so he can bill Blue Cross for a recheck? Maybe. But it's more likely that he wants his records to show how he made the existence of future risk abundantly clear and that he fulfilled any possible existing duty to inform me.

With that in mind, you might want to ask yourself: Do we remind pet owners to refill chronically used medication or to come in for follow-up glucose curves? If your medical records don't reflect that you reached out to clients in these regards, how could you rebut later client testimony that nobody ever made it clear, for example, that medical treatment for hyperthyroidism is an ongoing therapy? If nothing else, well-kept records are a way of protecting you and your practice.

Dr. Allen is president of the Associates in Veterinary Law P.C., which provides legal and consulting services to veterinarians. Call (607) 754-1510 or email

For a complete list of articles by Dr. Allen, visit


Source: DVM360 MAGAZINE,
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