The Importance of Documentation in the Veterinarian-Client-Patient Relationship

Posted by Justin May on Wed, 08/16/2023 - 12:34pm
veterinarian documenting in patient chart

The Veterinarian-Client-Patient Relationship (“VCPR”) is the touchstone of modern veterinary medicine. In this relationship, the veterinarian, the client, and the pet each play an important role in quality veterinary care. Having identified a problem with the pet, the client brings the pet to the veterinarian’s attention. The veterinarian uses his or her training and experience to assess the animal and consult with the client on a recommended course of care. Based on the veterinarian’s analysis and recommendations, the client is now empowered to make an informed decision on how best to secure care for the pet.

The key to success in the VCPR is quality communication. The veterinarian serves as a “learned intermediary” between the client and the pet. After years of training, the veterinarian uses his or her experience to evaluate an animal’s condition by receiving the pet’s medical history, performing a physical evaluation, and developing a differential diagnosis from which the veterinarian creates a recommended course of care. This process becomes second nature to a veterinarian, and often, the veterinarian can move faster through this treatment process to arrive at a recommendation.

Herein lies the danger. A practitioner can easily transition from a trusted advisor to a paternal practitioner as they gain experience and analyses become quicker and condensed. In so doing, the veterinarian’s risk exposure increases. Confidence can lead to increased risk tolerance, and abbreviated analysis can lead to information gaps between the veterinarian and the client.

The Dangers of Ignoring Documentation

I have counseled and defended practitioners for nearly ten years, and I have seen them fall into these traps. In my experience, the key to avoiding these pitfalls is often a practitioner’s least favorite part of the practice- documentation.

In one case, a practitioner evaluated a patient whose presentation was consistent with an infection. The practitioner recommended labs, which confirmed a urinary tract infection. The practitioner prescribed antibiotics and documented the file. However, the practitioner’s differential diagnosis was not documented. Despite verbally instructing on the differential diagnosis and recommending alternative courses of care, those conversations were never documented. Within days, the patient passed from myocarditis.

In another case, a practitioner performed surgery on a seriously compromised patient. Despite significant co-morbidities, the provider consulted with and evaluated the patient and determined to proceed with surgery under moderate sedation. During the surgery, the patient experienced loss of airway and entered cardiac distress. The patient ultimately died on the day of the surgery. When the investigation came, the record failed to capture the communication that occurred between the patient and the provider.

Lessons from These Situations

Show Your Work

A veterinarian is ultimately responsible for the exercise of professional judgment. A recommended course of care is based on the data available to the practitioner. The veterinarian's role is to compile the data, assess it, consider its significance, and recommend a course of treatment based on the veterinarian's medical judgment. In the context of the VCPR, this also means communicating the available data, the missing data, and the significance of both, demonstrating how the veterinarian arrived at the recommended course of care. Developing the habit of showing work helps veterinarians avoid abbreviating their recommendations and avoid paternalistic practice. Meanwhile, it educates and empowers the client in the decision-making process by informing them about potential diagnoses and courses of treatment.

Documentation is Critical

The adage goes that if it was not documented, it was not done. This is more than a defensive medicine motif. Documentation is a critical component of care for veterinarians, clients, and pets. It allows clinicians to record all of the data collected while providing care to a pet. In the long-term course of care, the significance of data can change over time as the clinician works through the differential diagnosis to determine the pet’s underlying medical condition. Without documentation, this data can become obscured or lost altogether as time passes and memories fade. Documentation also provides the client with another opportunity to receive guidance from the veterinarian. Some clients may benefit from oral discussion with a veterinarian, while other clients benefit from writings or visual representations, explaining the medical data and recommendations for the client to consider in making medical decisions. Moreover, documentation gives the client a reference point to recall information shared by the veterinarian and the veterinarian’s analysis to support the recommended course of care.

Never Underestimate the Value of Documentation

In short, documentation plays an important role in the VCPR and helps facilitate communication and a successful VCPR. Though often overlooked, veterinarians should never underestimate the value of client communication and documentation in the success of VCPR. It preserves critical data, shows the veterinarian’s decision-making process, and empowers the client to make informed medical decisions for the pet.

This material is for informational purposes only and is not legal advice. Transmission of this information is not intended to create, and receipt does not constitute an attorney-client relationship. The hiring of an attorney is an important decision that should not be based solely upon advertisements, certification, specialization, or self-proclaimed expertise. The information provided herein is intended only as general information which may or may not reflect the most current legal developments. This piece does not constitute legal advice and does not create an attorney-client relationship between Mr. May or Michael Best & Friedrich LLP with any person.

Justin May

Justin G. May
Partner at Michael Best & Friedrich LLP

Justin is licensed to practice law in North Carolina. He has years of experience representing health care providers in civil litigation,
licensing board matters, and healthcare compliance issues. He actively counsels and advises clients in the veterinary medical space. Michael Best is a full-service law firm with more than 350 lawyers and technical professionals in 17 offices throughout the United States, including Colorado, Illinois, North Carolina, Texas, Utah, Washington D.C., Wisconsin.

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