Medical Record Documentation

Implementation Date: 4/15/2010

Date of Last Revision: 4/15/2010

Next Review Due: 4/2023

 

Reviewed by VTH Administrative Team: 3/9/2010

Reviewed by VTH Board: 3/18/2010; 4/15/2010

 

Reviewed by Legal Counsel: N/A

Reviewed by Biosecurity Subcommittee: N/A

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

Policy

Records shall be maintained in such a fashion that any clinical staff, by reading the record, may be able to proceed with the care and treatment of the patient. The record should clearly reflect the initial problem, pertinent history, examination findings, tentative diagnosis, and plan for care and treatment and should be complete and accurate. VTH records should comply with AVMA and AAHA guidelines. Diagnoses, procedures and dates should be promptly recorded and records should not be back dated. Corrections or addendums should be made in a legally acceptable fashion.

Employees and students of the College of Veterinary Medicine are prohibited from adding or deleting charges and entering payments or credit adjustments into their own or a relative’s patient record.

Clinicians are responsible for completion of records by students under their supervision even if they did not examine the animal themselves.

Professional language should be used in the record. Derogatory and negative statements about clients or other health care professionals are inappropriate. These statements become a permanent part of the medical record

Guidelines

When entering data into the hospital information system (HIS), enter the actual date of the note, procedure or action taken, such as entering the weight. When entering charges into the HIS, enter the date the procedure was actually performed. All procedures must be entered, even if they are a no charge procedure.

In the paper record, only black or blue permanent ink may be used. Use of hi-liters makes it difficult to produce quality images and virtually unreadable when records are faxed. Limit their use and only use the yellow hi-liters.

In the paper record, each page must contain the client and animal identifying data, minimally the clinic number, client and animal name. In general, multiple patients may not be listed on the same form (exception is with FARMS patients coming in for simple elective procedures, healthy litters).

Limit the use of client and patient names in the body of notes or reports because this information should be redacted before being used for non-patient care reasons such as research.

Hospital orders, diagnoses, and certain notes/reports as outlined in other record template policies must be signed by a graduate 
veterinarian.

Data Changes/Corrections
To insure that changes requested for a patient or client, such as referring veterinarian (RDVM) changes, signalment, etc. are made accurately and in a timely fashion, as well as disseminated appropriately, a Correction Requested sheet should be completed and handed to a Medical Records staff person. Only the changed information needs to be completed.

Alterations in the paper record should be handled as follows: Place a single line through the change; write the date, reason and your initials near the change. The use of white-out, or obliterating information in the paper record is unacceptable. Also paper records may not be cut and pasted together.

In the HIS, for notes and reports that have been e-signed, an addendum may be added for additional information, or if the documentation is in error, should be retracted from public view where it may still be printed for legal reasons.

Timeliness
Clinical staff shall enter data into the medical record at the time of the patient visit or occurrence as much as is possible. Records shall be completed within seven (7) days of discharge. Unreturned paper records are considered incomplete records.

Hospital management may be notified when records and referral letters are not completed. The following consequences may occur when there are chronic problems with timely completion of records:
1. Search requests and access to records for research purposes may be denied
2. Travel monies and request for leave to travel may be denied
3. Withholding of intern/resident certificates may apply.

Abbreviations
Final diagnoses/procedures should be recorded in full without the use of abbreviations, unless the abbreviation is listed in the AAHA manual of abbreviations.

Referring Veterinarians and Consultants
Authorization to release information to a rDVM is normally obtained during the registration process. If a client informs clinical staff of a rDVM change/addition, or clinical staff refers a patient to another veterinarian, this should be documented in the record (e.g. client communication, or complete a correction form) so that records may be shared. When conferring with a consultant about a patient, the clinician shall document the consultant’s name and the interpretation or recommendations made. If the owner requests no release of information to their veterinarian, this must be provided in writing and presented to a Medical Records staff person as soon as possible so that all records may be promptly updated.

Consent Forms
VTH authorization or consent forms are prior approved by the University of Illinois Office of Legal Counsel and may not be altered without their review. If a client wishes to change/delete content of a consent form they should be informed that this cannot be done.

          Admission Consent
Clients should complete and sign an Admission Consent form (as well as a registration form/check in sheet) for each visit to the VTH and prior to being treated or diagnosed. During regular business hours this is done at Client Services. After hours it is the attending clinician’s responsibility. During an emergency, where the animal needs to first be stabilized, this information must be completed as soon as possible and prior to any nonemergency workup or treatment. Owners may elect not to allow images, photographs, recordings, or a likeness of their animal be utilized for educational and promotional activities on the consent form. In this situation, the owner MUST request, complete and return an Opt Out Likeness Policy form to Medical Records.


Rabies Certificates
A certificate should be completed for all dogs vaccinated for rabies. Only Illinois licensed veterinarians may sign rabies certificates.

Posting Patient Alerts in Records
Patient alerts should be posted to the HIS and the paper record as soon as possible. Examples of some common alerts are:
• MRS (Methicillin Resistant Staphylococcus) positive
• Allergic to Penicillin
• Muzzle
• No photos, images, or likeness allowed

For patients who are suspect or positive for an infectious disease, who later are no longer suspect or positive, the alert may be removed from the HIS (notify Medical Records). On the paper record, draw a line through the label and make a note of the date the patient is no longer suspect or positive

Procedure (if applicable)

When dating records, a day runs from midnight to midnight. For example, a patient comes into the ER at 12:01am on 3/1/10. The admission date is 3/1/10, not 2/28/10.

Medical Records will maintain a listing of clinical staff and student signatures/initials that may be used in the medical records for identification purposes.

Definitions (if applicable)

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.