[Dailydrool] Record Keeping

[Laura Tancredi]

Anita,
As a vet I so could not agree with you more.  I have worked in a variety of hospitals and record keeping has ranged from place to place.  It is the #1 reason for legal problems with veterinarians and I think human docs too.  My biggest problem at my current hospital is the old doc who owned the place is still there and so are many of the previous people as well.  All during that time they used 5 x 8 cards which you can't read and they stapled all the blood work folded over into the cards.  People tell them the doc a year or two ago told them something but they didn't write it down.  

I frequently get a record with NO paperwork or incorrect paperwork made up for the day.  I'm there until 11pm some nights (over 12 hrs of work at that point) doing paperwork myself and writing things up correctly.  It makes me look like an ass when the old dog only wrote "Healthy Pet, RV DHPP," but the owner is telling me they talked about something else.  Or worse there is a doctor there who has over 200 files on her desk that she hasn't charted from months ago!  Then we can't find the records because they are in a mess on her desk and the poor over worked receptionists are wasting there time looking through that avalanche of files. 

I worked at a place with paperless and that was good but there is the risk that information can get lost that way too.  Plus if a disk with radiographs, or CT came from another doctor we didn't have a place to put it.  Most owners keep no records what so ever nor do they know what's going on with their pet.  I know that I'm tired of staying hour after hour charting files but I'm even more tired of being the only one who does.  

I have found that the technicial skill of the people running the show determines the quality of the equipment.  The medical director and manager barely understand computers so we have very slow out of date computers and DSL internet.  The practice I worked in before with the paperless system was run by a doctor who was very into the newest in electronic equipment.  Although his practice and most general practices can't afford really nice equipment he knew that a digital radiograph was appropriate when the one from 1970 broke, and that when changing the computer system that it was time to go to paperless.  It was really cool because the doctors just put their notes in and their charges at the sametime.  AND when the blood machines finished running blood work it would automatically download the results into the record for that pet, same for the blood work sent to Antech.  So super cool.  

Ok my rant is over too but I recommend that you send a friendly letter recommending this to the practice owner and manager.  Let them know that you love the medical care they provide but think that perhaps an update in the computer system is needed and will help them retain clients and improve revenue.  

http://veterinarybusiness.dvm360.com/vetec/article/articleDetail.jsp?id=502345&sk=&date=&pageID=4

This is an article about changing over to paperless as well :)  

Good Luck!

Laura
Flash 
and Ryu