Welcome to There, I Said It- a column where we give you, the reader, a chance to get something off your chest in an anonymous fashion. Be it embarrassing, frustrating, or just something you didn’t want to admit out loud, it still might make someone else having a bad day feel just a bit better. If you have a story of your own, unburden yourself at TISI@drandyroark.com.
“Your medical records stink.”
Yep, I just said that. Right now you may be thinking, “Who is this person and where do they get off being so self-righteous?” Well, have I got news for you. If you are the one thinking these things, then your medical records probably do stink.
You know who you are. You are the one that is two weeks behind on medical records and somehow has the uncanny ability to extract from the nether regions of your brain accurate details of each pet’s comprehensive exam. You are the one that writes a two line history for a pet that presents for vomiting and lethargy for a week. Or maybe you are the one that frequently uses “PE = WNL” for the main body of your medical record.
By now, some of you are rolling with laughter and others are just rolling their eyes. You’re part of the problem too, even if you are one who does it right. This type of medical record keeping is so common that everyone shrugs it off. How many times have you been to a veterinary conference and people joke about medical record keeping when really it is not that funny? It is actually shameful.
Think about this for a moment. Everyone learned proper medical record writing in veterinary school. The state VMAs have been recommending and in some cases borderline begging us for almost two decades to put more effort into our medical records and have pretty much waved the white flag.
Uh oh, I know what’s coming. I just heard someone use the most common excuses: “We are still much better than the human side”, “My boss complains that I take too much time”, “I do not get paid enough to stay and finish my records”, or “I am the only one that is ever going to read it”. Any of those sound familiar? They probably do.
So, who is to blame? You are. I am. We all are. Why? Because as individuals, we should have enough pride in our education and skill set to strive to maintain a higher written standard. Because as business managers and owners, we should have enough intestinal fortitude to enforce a standard and lead by example. Because as veterinary medical governing bodies, we should hold businesses and individuals accountable for egregious medical record keeping.
It would not be fair to end this editorial without proposing some solutions. If you are an individual that truly believes in writing thorough medical records and maintaining a standard, do not sacrifice your ethics for others. Ask for time to finish your medical records during your shift. Ask for more “warm bodies” so you can spend less time “doc-teching” and more time completing your medical records. This isn’t a luxury, it’s a necessity.
If you are a business manager or owner, you need to have enough respect for medical record standards to enforce them with your veterinarians and hold them accountable. Value your doctors enough to provide them with sufficient staff for them to be able to spend more time on their medical records. Recognize that you may need to sacrifice on your bottom line in order to hire another doctor to create more time for all your doctors to be able to finish their medical records without each one working 60 hour weeks in four days. And, if you are part of a veterinary governing body, please start holding accountable those who blatantly disregard the written standards of our profession. Our integrity depends on it.
The views and opinions featured on There, I Said It are those of the authors and do not necessarily reflect the position of the DrAndyRoark.com editorial team.