Reviewing veterinary medical records
Black and White headshot of IndeVets Employee Marisa
Words by:
Marisa Brunetti, VMD — Chief Veterinary Officer

Our partner hospitals and employees know that we routinely solicit our doctors’ medical records and review them for detail and correct medical standards. This serves as an oversight function and an opportunity to connect with and mentor our IndeVets. Reviewing medical records is a task that is often talked about in hospitals but is rarely completed. When records are actually reviewed, there are rarely standards to judge against – and the most important person – the veterinarian – is often not involved in the process.

Here are my top tips for establishing and completing a medical record review for your veterinarians.

1. Establish your standards first

It is important to lead by example so your veterinarians have a framework from which to work. Your state’s practice act and other associations like AAHA and the AVMA can provide resources for ensuring your medical records are legal and comprehensive. An easy place to start is to require a SOAP for every animal examined, no matter the nature of the exam, and to require a detailed note for every communication with a client. I also recommend a medical record review worksheet to document the review of the record and provide recommendations in written form.

2. Ensure your veterinarians know your expectations

Communicate your standards to your veterinarians in written form and through discussion during your doctors’ meeting. This could include a standard SOAP template for them to use or modify slightly for their needs. Discussing these standards with them involves them in the process of building hospital policies and helps to ensure compliance.

3. Make it easy for your vets to achieve high record-keeping standards

Standard SOAP templates (including normal objectives) in your EMR system and standard communication templates can help to ensure your vets are compliant. If you have written medical records, a history and/or objective sticker can help ensure completion. Templates not only help ensure efficiency, they help prompt your vets to add important information they may forget (Vital signs including pain score, body condition scoring, muscle condition, differential lists, client communication, etc).

4. Establish and stick to a schedule for record reviews

The time to review a record is not after you receive a complaint or have a concern. Veterinarians should be reviewed routinely to establish trends in their reporting and communication. At IndeVets, we review our veterinarians within two months of their start date and then every six months thereafter. Two to three records are officially reviewed each time and spot checks are made throughout the year.

5. Involve the veterinarian in your review

This is the most important part of the medical record review! Hospital leaders can review individual vets or veterinarian colleagues can review each other as per your hospital’s protocol. Once reviews are completed and review worksheets filled out for each record reviewed, give your doctor the opportunity to review the worksheet and discuss the findings. This is an excellent time for coaching and discussion.

6. Stay consistent!

Veterinarians value consistency and feedback, and we are always looking to grow, learn and connect. Regular reviews and discussions on how I can improve have been invaluable to my career and emotional intelligence. All veterinarians deserve this process!

Dr. Brunetti is Chief Medical Officer for IndeVets.

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