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10 Common Questions About Veterinary Medical Recordkeeping Standards

10 Common Questions About Veterinary Medical Recordkeeping Standards

We're trying to think of everything when developing Instinct EMR.

Many hospitals using Instinct are accredited or pursuing accreditation by the American Animal Hospital Association (AAHA). These hospitals are evaluated against a set of more than 900 quality standards that cover all aspects of veterinary medicine, from patient care to team training and, of course, medical recordkeeping.

The medical recordkeeping standards in particular can be confusing, and they’re one of the more challenging groups of standards to meet.

💙 At Instinct, we’ve combed through these guidelines for you and use AAHA’s standards to inform our software development, which puts Instinct hospitals ahead of the curve.

We're frequently asked about these standards, so we put together this guide to some of the more common questions. We hope it helps your team to continue exceeding expectations.

For the most up-to-date and complete standards, please see AAHA’s published standards.

1. How long do I need to keep records? ⌚

“Medical records are retained for the length of time necessary to serve as resources for patient care, legal requirements, research, and educational tools” (MR 03).

AAHA does not provide a specific length of time in this standard. Rather, it states that records must be kept long enough to ensure good patient care and comply with applicable legal requirements.

Legal requirements for medical record retainment vary by state, but can extend up to 7 years past the last contact or treatment of a patient. You can find a handy AVMA guide to state laws here.

✅ Records in Instinct are kept (and safely backed up) indefinitely, which means veterinary hospitals that use Instinct are automatically meeting this standard.

2. How long can records stay editable? 🏃‍♂️

“To ensure confidentiality and integrity, the electronic medical record system automatically closes record notations after a user-specified period (maximum of 24 hours). Amendments/addendums are clearly recorded in an audit trail” (MR 48.1).

Finished records should be closed within 24 hours, and amendments or addendums must be added afterward as relevant.

✅ Instinct automatically abides by this standard, requiring amendments to be added if more than 24 hours have passed since notes were completed.

3. How can we ensure that veterinary patient records are secured appropriately?

A few standards that apply here, and Instinct helps with them all. ✅

🤫 Keeping records confidential

“Electronic medical record systems provide confidentiality and integrity by preventing unauthorized viewing or editing” (MR 44).

According to this particular standard, electronic medical record systems should prevent unauthorized viewing or editing.

Instinct secures all practice data (encryption in transit and at rest) and follows security best practices around log in, passwords, and time-out standards throughout our applications.

🔑 Classifying information by role

“The Practice Information Management Software (PIMS) utilizes role-based security, allowing specific practice team members, classified within various positions, different levels of access to viewing, adding to and/or altering information” (MR 50.1).

Role-based security is a key requirement for your PIMS.

Instinct makes it easy to assign different roles to team members, and each role has varying permissions to make compliance with this standard easier.

📜 Maintaining a written medical record protocol

“The practice utilizes a written protocol that details the maintenance of medical records. The protocol includes:

  • Who can write in the medical record
  • Information regarding the confidentiality of the medical records
  • Who has the authority to access the information” (MR 28).

Instinct helps meet these standards with a robust audit trail of everything your team does. AAHA standards also require practices to have a written protocol surrounding the maintenance of medical records, so make sure your hospital has a documented protocol and be sure to teach it as part of your onboarding process.

4. What does our hospital need to know about releasing veterinary records? 📧

“The practice utilizes a written protocol for how medical record information is provided to the client. This includes:

  • Who approves the communication of the medical record
  • The form in which the communication is delivered such as fax, telephone, email, or photocopy
  • Under what circumstances and in what form the medical record or supporting documents such as radiographs, diagnostic results, or veterinarian's orders can be delivered to the client” (MR 29).

✅ Instinct EMR has a robust Communication Log to appropriately record this information. You will also need to consider state and local laws about medical record release. The AVMA has a great summary of these regulations here.

5. What needs to be included in a patient’s medical history? 💊

AAHA standards (MR 22.1, 22.2, 23, and 24.1, specifically) define a complete medical history as one that includes the following components:

  • Current medications
  • Current medical therapy
  • Immunization history
  • Environmental history such as inside/outside, contact with other animals, other geographic areas
  • Client observations
  • Previous and current diets
  • Available information and patient history (including care at other veterinary practices)
  • Sufficient justify the tentative diagnosis, problems, and treatment
  • Client communication regarding their pet’s symptoms and changes in activities and behaviors

To make sure you’re addressing each of these components, you should have corresponding fields in your intake and hospitalization forms.

✅ Instinct allows you the flexibility to easily design and edit sleek templates to complement your hospital’s unique workflows and policies, and of course meet all the AAHA standards.

6. What should be included in physical examination documentation? 🐕‍🦺

“Physical examination templates are utilized within a structure consistent with SOAP or POMR formats. Entries about vital signs, ‘normal,’ ‘abnormal,’ and ‘not evaluated’ are complete. If findings default to ‘normal,’ yet abnormal findings are observed, the record is corrected at the time of entry within the same area of the template” (MR 40).

“Problem-oriented medical records are utilized. All medical records document patient medical information in a logical, organized and clinically oriented manner, and include:

  • Chief Complaint
  • Patient History
  • Physical Examination Results
  • Assessment
  • Plan” (MR 11)

✅ As with medical history documentation, you can use Instinct’s intuitive form builder to ensure your hospital is meeting all of the standards above.

7. When using outside sources, what type of information should be included in the medical record? 📠

“Medical records clearly reflect the following: Content or reports from professional consultations pertinent to the patient’s care, such as computer discussion forums, poison control, drug technical support veterinarians, veterinarians who have previously rendered care to the given patient, and rounds discussions with other veterinarians” (MR 21.u).

✅ Instinct EMR allows easy drag and drop of all types of files including audio, video, or image files and PDFs.

8. What needs to be documented about client communications? 📞

“Medical records clearly reflect the following: Client communication, including unsuccessful attempts to reach the client, means of contact such as by telephone or email, and who was contacted” (MR 21.j).

✅ Instinct’s Communication Log is always one click away, which means encouraging thorough communication logging is practically effortless. As the common saying in our field goes, if it isn’t documented, it never happened!

Before treating a patient, your team must obtain authorization from the client. Consent forms, treatment plan, and associated fees/estimate must all be signed by the client as part of a complete medical record (MR 21t, 21t.1).

However, having signed forms is not enough. Before signing, clients must be educated about the plan and recommendations that are being presented (ie, informed consent).

Components of informed consent include:

  • Potential benefits and drawbacks of recommendations
  • Potential problems related to recuperation
  • The likelihood of success
  • The possible results of non-treatment
  • Any significant alternatives
  • Financial responsibility (MR 32).

✅ Instinct has a unique on-screen signature feature that automatically logs the attending staff member as the witness in the legal record.

Make sure to teach staff to go over each of these points with a client before asking them to sign. And if the client declines care, don’t forget to have them sign the appropriate waivers (eg, Against Medical Advice) which can be created in Instinct to meet standard MR 21.m.

10. Is there anything else I should know about AAHA’s medical recordkeeping standards? 💡

There are a couple standards that can be easy to overlook—specifically these two, regarding abbreviations and patient weight.

🔤 Using shorthand and acronyms

“Where abbreviations are appropriate, standard abbreviations are utilized” (MR 05).

We all try to save time in documentation by using shorthand and acronyms. However, many abbreviations are only recognized locally (either within a specific hospital, in a specific hospital group, or in a specific geographic region).

To ensure your documentation stands up in a trial if one occurs, make sure that any abbreviations used in medical records are standard. If you aren’t sure, take the extra time to spell it out!

🐶 Weighing the patient

“The patient's weight is recorded in the medical record each time the patient is presented to the practice” (MR 18).

It's easy to skip, but this is important: Don't forget to weigh your patient at every single visit!

Overall, navigating medical recordkeeping standards can be difficult. Our best tips? Have written protocols, ensure compliance, and use technology wherever you can.

Industry best practices are a central focus for the Instinct team and hospitals that use Instinct can rest assured that we're constantly dreaming up ways to help teams meet and exceed these standards. In fact, helping your team exceed standards and continue to provide the best care is the ultimate reason we exist!  🤜🤛💥

About the Author

Lyla Kotsch is a third-year veterinary student at the University of Georgia. She interned with Instinct in the summer of 2020 and continues as an Instinctual part time throughout the year. You can read more about her experience here.