BUSINESS OF PRACTICE: MANAGING ACCOUNTS RECEIVABLE 2. Medical
From a medical standpoint, records exist for document- ing examinations, treatment, communication, and the continuity of care. Records should be accurate, clear, and timely. Whether handwritten or digital, they must be legible and easy to follow. A SOAP (subjective, objec- tive, assessment, plan) format is highly recommended. Minimum requirements for medical records vary from state to state based on the state’s veterinary practice act. Equine practitioners should review these require- ments against their current practice to see if the mini- mum information is being captured in their current record keeping format. If practitioners are licensed in multiple states, medical records should meet the stand- ard of the state with the most requirements. Complete and legiblemedical records are imperative both in hospi- tal and in ambulatory practice. The quality of care will be judged on the documentation within the medical records. Documentation should show sound professional judgment based on information available at that time. For example, if a lameness exam is done with nerve blocks or joint blocks to localize the affected area, a thor- ough understanding of the results, i.e., percentage of lameness improved, should be documented to justify the recommended course of treatment. In addition, good documentation will ensure continuity of care should the horse be moved or treated by another equine veterinar- ian. A good rule to follow is that any equine practitioner who reads a medical record should be able to pick up where the last veterinarian left off with treatment of that horse. Items to include inmedical records are writ- ten consent forms, anesthesia logs, surgery reports, physical exam findings, daily boarding sheets, reproduc- tion exams, diagnostics recommended and declined by the client, lab results, estimate sheets, and all communi- cation including texts, e-mails, voice messages and verbal conversations. The practice owns these records, including original radiographs. The client of the records is entitled to copies upon request within a reasonable time period. Consult your state veterinary practice act for specifics regarding providing records to clients. And remember to check with your state veterinary practice act as to ALL specific record keeping require- ments, including howlong records should be maintained (see below under regulatory for an example of a state veterinary practice act). Lastly, medical records also are an open component of communication practices. Dep- ending on what record keeping system is used in the practice, texts, emails, voicemail messages, social media posts, and verbal conversations should be captured and maintained as part of the medical record. Documented conversations around risks help show informed consent particularly if a compounded or off-label medication is going to be used.
3. Legal
Medical records are a legal document and are required to bemaintained under the lawof the state practice act. From a defense standpoint, if something was not
122 2022 / Vol. 68 / AAEP PROCEEDINGS
written in themedical record, it did not happen. Equine practitioners can benefitfrom using a SOAP format to avoid legal pitfalls. Licensing boards and attorneys pre- fer to seemedical records in the SOAP format, and they should be accurate and up to
date.Using amedical soft- ware system that has time and date stamps is prefera- ble. If doing ambulatory work, utilize a system that syncs automatically, and if it does not, then have the re- cord updated within 24 hours of the last visit. Many state practice acts will stipulate a timeframe in which a record must be updated. Amendments should also be date and time stamped along with the justification for the amendment. Telemedicine is being utilizedmore fre- quently by equine veterinarians and this type of technol- ogy has many benefits both to the practitioner and the client. These visits should be maintained in the formal medical record. Guidelines around telemedicine con- tinue to evolve and practitioners need to be aware of the legalities of utilizing telemedicine in their state. Most states and the AVMA Principles of Veterinary Medical Ethics (PVME) still require that a valid veterinary-cli- ent-patient relationship (VCPR) exists in order to diag- nose, prescribe medication, or treat an animal.a The AVMA has resources on telemedicine and these should be consulted to ensure that current methods are within the legal scope of practice for the state(s) that the veteri- narian is licensed in.b Finally, the medical record is not only a legal document, but also a confidential one and veterinary practices need to ensure that client confiden- tiality is maintained. Medical records should only be released to the client upon request. Some states have seen amendments to state practice acts in this area of confidentiality to allow for more transparency within horse racing jurisdictions among trainers, veterinarians, and regulatory authorities.
4. Regulatory
Horse racing is just one area where veterinary medi- cal records are used for regulatory purposes. The increase in oversight on many racetracks has cast a spotlight on the medical record keeping practices of equine racetrack practitioners. This is one area where historically, the medical records were comprised mostly of invoices which represents a violation of most state practice acts. The increase in regulatory requirements onmany racetracks has brought aware- ness to the medical record keeping area of racetrack practice with many practitioners now believing the lack of detailed medical records as substandard prac- tice.2 State licensing boards regulate veterinarymedi- cine through enforcement of the veterinary state practice act. Licensing boards may find in favor of the veterinarian’s medical treatment based on a license defense claim but will issue a fine for lack of proper medical records since the board has access to review
all the medical records when a client complaint is filed. This is where equine practitioners need to be aware of the minimum record keeping requirements for their state and address their current format of medical records against this standard. For example,
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