Medical Records 

VitalRads Radiology Pearls 

Medical records are important. So much so that they are a legal document that needs to be able to withstand a judge’s or court’s scrutiny.  We all know that.  But making yourself keep your records up to date, accurate and organized can be a challenge. There is not much worse than looking back at a patient’s record and finding that the information in the record is not up to date, not accurate or perhaps, not even there at all.  It takes time to write records. Often times, records are placed in a pile on your desk with good intentions to go back and write them more completely – maybe at the end of each day. Some take them home to catch up on entries in them in the evening or over a weekend.  As important as medical records are, they are equally a pain to complete. 

Included in the medical record for each patient should be your professional notes as they pertain the animal patient, copies of all lab results, including bloodwork, cytology, histology and yes, a “radiology report.” Most veterinarians send bloodwork, cytology and tissue samples to an “outside” referral lab service; the lab renders a written medical report on their findings, which is then included in the patient’s medical record. Radiographic and ultrasound images should be no different than cytology reports or bloodwork results. Using a teleradiology service for all of your imaging studies is not only the “standard of care” in veterinary medicine, it also will provide you with a report for each study done in your practice, thereby significantly boosting the quality of your medical record. However, for some reason, many veterinarians do not make an entry into the medical records for any imaging studies at all.  Sure, you might (notice I use the word “might”) have the films available for future reference if needed, but this will not help you if something goes sour and you find yourself trying to defend your position in a court of law. Having a well though-out, organized, concise report for each imaging study you do will go a long way in decreasing your liability for the lack of a medical record for each study AND it will almost certainly lessen your own professional liability if something was missed on the film. If a boarded specialist reads out your cytology, histology, or radiographs, it typically switches the majority, if not all, of your liability for interpreting these studies to the specialist and away from yourself!   

Another tip for keeping your medical records up to date and minimizing the time you have to spend doing this, is to check out voice recognition software. I started using this in our radiology practice many years ago, and at that time, it did not work very well and took a lot of time to train the computer to try and increase the accuracy. Well, those days are gone. If you purchase the correct software and speech equipment, voice recognition can save you HOURS of time each week. Instead of typing into your electronic records you can simply talk in a normal way to your computer, and it will copy what you are saying in real time into your records. If you have any questions about our services or veterinary specific voice recognition software, please let us know. We can advise you on what you need to purchase and how it will integrate with your practice management system. Voice recognition is like magic – except it’s not magic, it’s real (and very accurate).