Clinical Communication Notes

Implementation Date: 4/1/2009

Date of Last Revision: 4/2009

Next Review Due: 4/2023

 

Reviewed by VTH Administrative Team: 2/17/2009

Reviewed by VTH Board: 2/19/2009

 

Reviewed by Legal Counsel: 2/5/2009

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Administrative Team without Board approval.

Policy

Communications with clients and third parties, including referring veterinarians, shall be documented in the electronic Medical Record. Attempts to reach clients shall also be included, however, personal or confidential information should not be left on voice mail without the owner’s prior consent. Communication summaries shall be completed in the hospital information system and verified (pinned with password) by the author as soon as possible. Email communications may be pasted into the electronic communication summary screen. 

Guidelines

1. Only the person speaking with the client or third party shall document and sign the communication summary.
2. Include the name of the person spoken to rather than just ‘client’ or ‘owner’ in the communication summary.
3. The body of the communication summary should include the date and time the conversation occurred if it is different from the date and time the summary is entered.
4. Document all attempts to reach clients and rDVMs. If the party is unavailable, document that a voicemail was left.

Procedure (if applicable)

The communication summary will no longer be printed and signed for inclusion in the paper record. Before a summary is verified it may still be edited. Once verified, a communication summary may only be updated by adding an addendum, which does not change the original entry. To correct an error in a communication summary, it must be retracted and re-entered. Retracting the notation removes it from public view while maintaining an unobliterated document that may be accessed by Administrators. To have a communication summary retracted, send an email to Medical Records at medrec@vetmed.illinois.edu (include the specific reason for retracting the summary for auditing purposes).

Communication notes not verified within 48 hours, by default setting in the hospital information system, will be locked and no longer editable.

Definitions (if applicable)

Client: A person(s), association or corporation that has entered into an agreement with, the University of Illinois College of Veterinary Medicine (CVM) for the purposes of obtaining veterinary medical services, who has consulted with the CVM with the intention of obtaining services, or a veterinarian who has referred cases to the CVM. 

Third Parties: A person(s), association or corporation who may or may not have a direct association with the client, and is not the legal owner of the patient (e.g. insurance companies, trainers, law enforcement agencies, pet sitters, etc.).

Locked:Reports by default setting within the hospital information system may be set to be locked within a given number of days. Once the report is locked it is no longer editable. An addendum may be added to the report, or the report may be retracted from view and rewritten.

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.