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Veterinary Forum May 2008 (Vol 25, No 5)

Doctor to Doctor: Meticulous medical records

by Ronald E. Whitford, DVM

    Accurate record keeping will become even more important to veterinary practices as owners continue to think of pets as family members and demand higher-quality medicine.

    Specific forms used in your practice should be developed to ensure thoroughness as well as to provide opportunities to market additional services to clients. It is important to consider all forms as "miniature billboards" that represent your practice. All written materials bearing your practice's name should enhance the practice's overall professionalism. The cost to develop more eye-pleasing forms is minimal over the life of the form and can make a tremendous difference in the eyes of your clients.

    Although computers have helped make practices more efficient, they also can generate a lot more paperwork. It is important to constantly evaluate the paperwork that is computer-generated and to discontinue any reports that do not have a specific purpose or are not reviewed on a regular basis.

    Turning your practice into an efficient paperless machine can put an end to problematic file duplication, missed charges and having to write the same information many times a day. The elimination of paper often brings a veterinary practice to the next level of care, but there are some caveats to review before taking the plunge.

    All staff must become computer literate for the changeover to work, but this is becoming less of a problem because upcoming generations have been raised on constantly evolving technology. In general, technicians and assistants will be responsible for inputting most data into the system — often during the short time that a pet is in the examination room — so thorough, practical training is necessary from the start.

    It is a good idea to continue to use some paper forms, such as consent and new client forms, and then file each in an individual folder on a weekly or monthly basis rather than scanning all of the material into the system, which would require more labor, scanning devices and computer memory than may be available.

    Backing up the entire system is mandatory at least once a day. Consider installing a mirrored hard drive on the server and be sure to keep a copy of the backup off-site. A good way to do this is to use a different backup disk each day and take the most current one off-site every night or use a service that backs up and stores data off-site.

    To remain in compliance with the law, medical records must be unchangeable after 48 to 72 hours. This can be accomplished by burning a new CD for each day's data.

    Another recommendation is to "burn in" new computers during the first 2 weeks of operation by leaving them on at all times. Most electrical problems will surface during this time.

    Eliminating paper and going digital can be a rewarding and profitable venture, but it does require some sacrifice and hard work. When in doubt, consider meeting with a practice management or technology consultant to keep you on the right track.

    NEXT: Editor's Note: Cause, effect and coincidence

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