THE BUSINESS OF PRACTICE


below and above the lined areas. Again, this may encourage a lawyer to claim that entries were added to the medical record at a later time. 3) Anything that is changed should have a single


line drawn through it. The reader should be able to read what has been crossed out. There should be a date, time, and signature along with an explanation as to why the item was crossed out. An example of this would be with “2/19/2012 written in wrong chart” written next to it and then signed or initialed. 4) Do not go back and add anything to the record


on a previous line. If you forgot something put it on the next available line and write “addendum” at the beginning of that line and state the time that the item was performed. 5) Everything that is discussed with the owner, trainer, insurance company, referring veterinarian, consulting veterinarian, and so on, should be writ- ten in the chart. Even conversations that occur in remote locations should be added into the chart as soon as possible. 6) Additionally, all treatments and observations throughout the day should be listed. Mundane ob- servations such as fecal production and water con- sumption can become important if a hospitalized horse has development of colic. Even in the ab- sence of disease, these observations are evidence of your continued monitoring and care of your hospi- talized patients. Certainly, all procedures and all physical exam findings should be placed in the re- cord. Normal findings are important to record be- cause they may protect you in the future. For example, if you do not record a horse’s normal tem- perature, you cannot prove that it did not have a fever or that you even checked its temperature. 7) If consent is needed you should have the owner


or agent sign the consent form. If this is not possi- ble and consent is given over the phone, you should consider having two people gain consent from the owner. Both people should record it in the medical record. A faxed, signed consent from the owner can be added to the record until an original can be obtained. 8) On field calls, your physical examination should


be recorded. An example is that when you look at a foal with contracted tendons you should not just record “bandages applied.” You should explain why you are doing any procedure. In this case, for example, for treatment of bilateral front fetlock con- tracture. Detailed information is important. In this case, for example, if tetracycline was given, then record the amount that was given and if it was diluted in a liter of saline and given through a catheter. 9) If multiple treatment options are given to an


owner, be sure to record each option, with all perti- nent information such as projected costs and prog- nosis. You should record which option the owner chooses and, if possible, why the owner chose that option. This is particularly true if the owner or trainer declines referral. Make sure that you re-


cord that referral to a specialty center was recom- mended or offered. If you consult with a specialty clinic about any case, record the communications with that clinician. 10) We recommend having the owner/agent sign


the farm call invoices to acknowledge that the treat- ment was administered. Confidentiality is paramount in any medical pro- fession. A simple way to anger a client is to disclose private medical information concerning their ani- mal(s) to a third party. As a referral hospital, we routinely have performance animals in our barn. When a client is in the barn, he or she may recognize the animal and ask questions regarding its condi- tion. Disclosing information could greatly affect an animal’s value, result in significant problems with an owner, and potentially cause a lawsuit. We cover any names on halters with white tape. Re- cords are kept in an area where only employees have access. It is very important to emphasize to your lay and professional staff that they should not dis- close any medical information about a client’s horse to anyone—this includes even confirming that the animal is present at the hospital. In high-profile cases, the client is consulted and dictates the amount of information that we can release, if any. Additionally, all employees have a confidentiality clause in their contract, and lay staff members sign a confidentiality agreement. The most important thing to remember with re-


gard to communication is to be honest with owners. Mistakes will occur, but that is not equivalent to malpractice. Open communication and explana- tion are critical. An example of this comes from orthopedic surgery cases: on occasion, drill bits or screws can break, and these issues should not be hidden from owners. Communication must be ini- tiated, including prognosis, treatment necessity, and options. We referred a yearling Thoroughbred horse back to its original surgeon to remove a trans- physeal screw that he had placed. There were is- sues with the placement of the screw, and we believed that the surgeon who placed the screw would be better prepared to remove it. After sur- gery, the horse was returned to the farm, with no problems reported. Four months later, while tak- ing survey radiographs for the yearling sales repos- itory, it was discovered that the screw had broken off, and half remained in the leg. This information could have been better handled if we had known about it before the sale. Another example seen frequently involves the in- tra-arterial injection. As long as you have used normal accepted procedures when giving an intra- venous injection, recognized the problem when it occurred, and treated it appropriately, malpractice is not an issue. This is a known complication and accepted risk. I often hear owners being told that their horse had an allergic reaction to a particular drug—not to an intra-arterial injection. This is an unnecessary lie that makes things more difficult


AAEP PROCEEDINGS  Vol. 59  2013 283


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