Equine veterinary medical records
The Board has noted recent complaints about veterinary practitioners who practise in equine veterinary medicine or surgery where the relevant veterinary medical records fell short of the required standards.
Board Guideline 7 – Veterinary medical records outlines specific requirements on the timeliness of making records and the content of a record. These requirements apply to all practices including ambulatory (mobile), off-site practice and practising in a clinic or hospital premises.
Complete and legible records of consultations, decision-making, services delivered and veterinary medicines prescribed and supplied are important wherever a veterinary service may be delivered.
The Australasian Veterinary Boards Council’s (AVBC’s) Day One Competencies require veterinary practitioners to maintain accurate, consistent, and contemporaneous records in a clinic database, which allows for case transfer and protects client privacy. The AVBC’s guidance for new graduates on this competency is that ‘patient records should be sufficiently clear that they can be referred to by others and (if written by hand) be legible. Professional terminology should be used, avoiding idiosyncratic abbreviations or jargon’.
Further, the code of conduct in Australian Veterinary Association’s policy Provision of optimum veterinary services to the horse racing industry says, ‘Veterinarians involved in the horse racing industry… should keep detailed, professional, objective and timely clinical records of all examinations, advice and treatments.’
The Board recognises that vets are not sitting in front of a computer when they are out in the field, but increasingly there are ways to easily record the results of examinations, discussions and treatment in the field. For example, it is possible to make voice notes using a mobile phone, then later complete a record based on those notes.
Your documentation should show how you exercised your professional judgement when conducting an examination and interpreting results in the field.
Clear and accurate veterinary medical records are essential for the continuing good care of an animal and keeping the public safe.
The test of a good record is if any other practitioner could take on the treatment of an animal with a complete understanding of your inquiries, decisions made and the services and medications provided. In the case of a complaint, the Board wants to understand your approach and why you made your clinical decisions. Contemporaneous medical records are the first step in providing that context and gaining that understanding.
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