Participants
Beth Venit, VMD, MPH, DACVPM, American Association of Veterinary State Boards, Washington, District of Columbia
Kate Boatright, VMD,Write the Boat, Grove City, Pennsylvania
Sarah L. Babcock, DVM, JD, Animal & Veterinary Legal Services, Boca Grande, Florida
Moderator
Katie Berlin, DVM, Instinct Science
Dr. Katie Berlin:I’d like to talk about documentation and medical recordkeeping. How much does documentation protect you if a client remembers something differently than you do?
Dr. Beth Venit:Despite our best efforts, documentation doesn't always prevent a disciplinary complaint; however, documentation is your best resource for having a complaint dismissed. As long as you have good medical records to back up your decisions and it is reasonable to assume other clinicians would have made the same choices, you should be able to feel more comfortable about the outcome.
Dr. Sarah Babcock:The medical record should tell a story. It should provide an idea of the decision path, document client discussions, and include the pros and cons of decision-making. It can be tempting to write something lengthy, but presenting notes as a checklist can make it easier for the client to see and read and thus absorb and understand information during a stressful situation.
The medical record can also help ensure continuity of care; being clear about what you did and why is important. For example, if you omit a diagnostic or treatment option based on cost, not only do you need to document why, you need to show the decision was supported. So, if you did a cost–benefit analysis and talked to the client about it and the client elected not to proceed with a reasonable range of options, that should be included in the record.
You can't simply dismiss something and say, well, it cost too much. I like to say, it's you, your client, and your medical record. The medical record is your third-party witness. Anything you can do to help make sure that third-party witness reflects your professionalism and the quality of care you provided will be helpful.
Dr. Venit:If a client decides not to proceed with a treatment, an against medical advice (AMA) form should be included in the record. I make sure it's clear that an AMA is merely a statement of the decision, not a statement of judgment. When presenting a client with an AMA, it is important to be empathetic and say something like, I understand this is a difficult situation and you can't proceed with the recommendations. If your circumstances change, I am here. I want to see you again, and I want to help.
An AMA can also be used as a checklist of what was recommended. The client can sign at the bottom, or they can sign every item. The client can then refer to the AMA when they get home. If circumstances change, the client can come back and say, let's do item number 1 or 3. That documentation is also an amazing piece of evidence if there is a complaint because you can show that each item was discussed and signed by the client.
Dr. Kate Boatright:Presentation is also really important. I try not to call it an AMA form in front of the client, because like you said, guilt is a huge driver. Ultimately, even though documentation is our shield, communication is our most effective tool in actually preventing complaints from happening in the first place.
Dr. Babcock: I like to provide discharge instructions. These can include what the patient should be monitored for, what to do in case something happens, and next steps. I try and keep it in the tone that this is a shared decision-making process; you're in it together, and you come up with this document together. Don't send a team member with a blank sheet for the client to sign. Make it one of your communication tools.
Dr. Berlin: Is there a legal difference between a checklist document the client has signed and discharge instructions?
Dr. Babcock: The difference is how it impacts your relationship. I think it doesn't matter what you call the form; it acknowledges the client is leaving, the patient is being discharged, and these are the things to watch for and what to do if the client changes their mind.
Dr. Venit: And in fact, having an alternate plan for follow up care is required in many practice acts.
Key Takeaways
Medical records do not need to be lengthy, but they do need to tell the story of your decision path and conversations with the client.
Make AMA forms informative and useful for the client, and keep conversation around treatment decisions nonjudgmental.
Always ensure clients know where and how to follow up if you are unavailable.
Thorough records can help defend you in case of a board complaint, but good communication is the best way to avoid complaints in the first place.