Veterinary Records: If it’s Not in the Records, it Didn’t Happen

Dr. Jones had been practicing small animal veterinary medicine for over 25 years. She had a nice rural practice and a good relationship with her many clients and their pets. Around 10:00 p.m., a client called her because her small dog, Rover, had been injured playing in the yard and was bleeding badly from a puncture wound. The client was frantic to bring Rover to Dr. Jones even though it was after business hours. Dr. Jones politely suggestion the client bring Rover to the emergency clinic, however, the client insisted Dr. Jones treat Rover. She relented.

Upon examination, Rover was still very aggressive and was trying to bite Dr. Jones and its owner. Dr. Jones administered a pain medication and when that did not work she administered a small dose of anesthesia. Once Rover was sedated, Dr. Jones treated the animal. She informed Rover’s owner that the wound was not life-threatening. Rover would fully recover.

The pet’s owner insisted that the dog come home with her because the owner’s work schedule did not allow her to leave the dog at the clinic. Dr. Jones told the owner that if she was going to take Rover home, Rover would need to be closely monitored and placed in a sternal recumbent position until the medication wore off and the dog was alert. Against the doctor’s advice, the owner took the dog home.

Six hours later, the pet’s owner called Dr. Jones and informed her Rover was dead and that she was very angry with Dr. Jones over the death.

Six months later, Dr. Jones received a letter from the Board of Veterinary Medicine stating that Rover’s owner had filed a complaint against her. The Board requested that Dr. Jones forward Rover’s medical records to the Board as a part of its investigation. As a licensed veterinarian, Dr. Jones was compelled by law to cooperate with the Board and turn over his records.

The Minnesota Board of Veterinary Medicine Rules requires that every veterinarian maintain medical records on the animals they treat. Rule 9100.0800, Subp. 4(A) requires the following information be contained in the medical records:

(1) Name, address, and telephone number of owner;

(2) Identity of the animals, including age, sex, and breed;

(3) Dates of examination, treatment, and surgery;

(4) Brief history of the condition of each animal, herd, or flock;

(5) Examination findings;

(6) Laboratory and radiographic reports;

(7) Tentative diagnosis;

(8) Treatment plan; and

(9) Medication and treatment, including amount and frequency.

Dr. Jones’ records for Rover were stark in comparison to what the rules require. Though the basic information required by items 1 through 3 was recorded, the records lacked much of the detail required in items 4 through 9. Even though Dr. Jones had done everything correctly in treaty the animal, not everything she did that night was recorded in her records. Most importantly, there was no notation that Rover’s owner had taken the pet home against her advice.

Clearly, if Dr. Jones had made more accurate medical records, her recollection of her treatment of Rover would have been corroborated by the medical records.

What are the standards for record keeping? According to the Executive Director of the Minnesota Board of Veterinary Medicine, a veterinarian must comply with Rule 9100.0800, Subp. 4(A). In addition, enough detail should be provided so that another veterinarian, unfamiliar the pet, could step in, read the pet’s medical records, and pick up where the original veterinarian left off.

A veterinarian needs to maintain medical notes with an eye toward protecting himself/herself from claims of negligence by his or her clients. If it is not in the medical records, then it did not happen. The extra time that it takes to make more detailed notes is well worth the effort.

Characters in this article are fictional and any similarity to actual people or events is coincidental.