It's 10 a.m. on Monday morning. Mrs. Hodge rushes in with her 13-year-old miniature Schnauzer, which is lethargic and vomiting.
The problems began yesterday, and all Mrs. Hodge can tell you is that she's been giving her dog some kind of pill for the
past week. So you race to the file and look for the notes. There are none. What was the diagnosis? What's the medication?
What tests were performed? You scramble to find a note or a lab report—even a receipt might give you an idea of the dog's
history. Nothing. And here's the kicker: Mrs. Hodge's regular veterinarian is on safari in Africa.
Even if you've never found yourself fumbling foolishly through incomplete files while your partner, boss, or associate was
off snapping photos in the savannah, you've struggled with—or absentmindedly written—lousy medical notes. As successful doctors
we communicate with clients about the necessity of a diagnostic test, the prognosis of a disease, and the importance of anesthetic
monitoring. Yet sometimes we fail to communicate with our own colleagues. When we don't, the patient's diagnostic or treatment
plan may fall apart, we open ourselves up to legal trouble in the future, and we don't present a consistent message that gives
pet owners confidence in our practice.
Andrew Rollo, dvm
When the situation isn't dire, incomplete medical notes can occasionally be comical. One time when I was reviewing a patient's
records, the only note I found from the pet's previous visit read "roast beef." Either this was the shortest description ever
of a case of pancreatitis, or the doctor was already thinking about lunch. But these situations can also be embarrassing for
the practice and costly to the owner—for example, when a doctor orders a thyroid profile that was already sent out the week
before. Even worse, something like an unnoted drug allergy can be downright dangerous to the pet.
A lack of good medical notes puts an unfair burden on the next doctor, who must spend extra time figuring out what the original
doctor was thinking. The second doctor may have to ask the owner what tests were run and what drugs were prescribed—not exactly
something that inspires client confidence. Plus, the client may report that a prescribed steroid didn't help Bruiser's itch,
but how many owners can tell you exactly which steroid was used and at what dose?
So get in the habit of good note-taking. Ask your technician to write your notes if you're in a hurry. At our hospital we
have monthly medical record audits. At a doctors' meeting we grade 10 files from a particular doctor based on a set of standards
we've all agreed on. Doctors are generally used to getting good grades, so it doesn't take long for the note-taking slackers
to shape up when they start getting F's. And even though we're critiquing each other's work, we still try to have fun at these
meetings. It's not unusual to order some roast beef sandwiches.
Dr. W. Andrew Rollo, a Veterinary Economics Editorial Advisory Board member, is an associate at Gibraltar Veterinary Hospital in Gibraltar, Mich. Send questions or comments