Please Stick to the Paper Trail

As the legal representative on the AVA / Guild Insurance risk management committee, David Short of Meridian lawyers, provides the following guidance to help address the common and recurring themes that are often at the heart of claims and complaints examined by the group, and also in those matters that require the defence of veterinarians subject to claims.

1. No matter how strong their technical skills may be, vets run a real risk of at some stage of their career being on the receiving end of a complaint by a dissatisfied client, whether by way of a compensation claim or a disciplinary complaint to a regulatory authority.  Having a good paper trail of your dealings with the client will substantially increase the prospects of successfully defending such a complaint, which may otherwise have significant impact on your reputation as well as your financial position.  

2. When providing treatment, a vet is often alone with the client.  If that is the case (and even if another staff member is assisting in the background), if you do not have available clear and detailed clinical records, a complaint can quickly become a case of "did not, did so".  Without necessarily disbelieving a vet, it is not uncommon for a disciplinary board or judge to conclude that the complainant's version of events should be preferred as he or she is likely to have a better memory of the events in circumstances where they are alleged to have been life changing ("that dog was my best friend"; "that horse was going to win me the Melbourne Cup") whereas the vet's memory may be clouded as a result of the number of clients seen in the intervening period between the subject treatment and the hearing of the complaint.

3. In that regard, it is to be borne in mind that it can be years before a complaint is determined.  Can you accurately recount from memory each treatment provided in the last three years?  What happens if the treatment was provided by a staff member who left your employ years ago to go overseas?

4. There is also the risk that poor clinical records may be seen as indicative of broader sloppy veterinary practice.  Conversely, cogent and well-ordered records should provide to those determining the complaint a strong impression that the practitioner maintains high standards across the board.

5. By way of a general guide, clinical records should at least cover the following matters:

   • Client details (such as name and address of the client and details of the animal treated);
   • The date of each treatment or consultation;
   • The history provided by the client and the animal's presenting problem;
   • The assessment undertaken and the findings on assessment;
   • The treatment plan and estimated cost;
   • Information and advice provided to the client, particularly in relation to warnings as to relevant potential adverse outcomes;
   • The treatment provided; and
   • Post care instructions provided.

6. It is important that your clinical records are just that – clinical.  Do not record personal or offensive comments about the client – as a rule of thumb, if you would not say it to their face, do not write it down.   A personal or offensive comment will, at the very least, be embarrassing to you if the records are required to be produced in response to a complaint and may well adversely affect the outcome of that complaint.

7. Get into a habit of consistently preparing your notes, whether that be as you go through the course of the consultation, immediately after each consultation or at the end of each day.  In relation to the latter, given you will likely see a number of clients through the course of the day, it is a good idea to take brief, shorthand notes contemporaneously which will assist you when it comes time to prepare your clinical records.

8. If you use abbreviations, use them consistently and, where possible, adopt abbreviations commonly used by the profession and/or in the community.  Ensure that your staff utilise the same abbreviations and that those abbreviations have a standard meaning throughout the practice.  It is not helpful if you use "L" to mean left, whereas your employed vet uses it to mean lumbar.

9. If you create handwritten clinical notes, make sure they are legible – if you cannot read them no one else will be able to do so and they will not be worth the paper they are written on. 

10. One sub category of the paper trail which is often critical in defending complaints relates to informed consent.  Before any treatment, the client must be given sufficient information to enable him or her to make an informed decision as to whether to proceed with the treatment proposed.  This will involve describing to them the diagnosis made; what further investigations may be required; the treatment options available; the likely costs involved (and, if this estimate changes during the course of treatment, make sure you update the client); and potential adverse outcomes.

11. It is important that you communicate these issues in a manner in which the client will understand them.  Do not use scientific terms or other jargon if it is unlikely to be properly understood.

12. It is critically important that the process of informed consent is documented and that an acknowledgement is obtained from the client that they understand the issues in question and agree to a particular path being adopted.  If at all possible, ensure the acknowledgement is in writing.  Some practices add an informed consent section to their standard admission form which the client signs once the appropriate discussion has taken place.  You could even think about having the client sign your clinical notes where you have documented the discussion.

13. As with anything to do with a paper trail, what is critical is the fact and content of the documentation rather than the manner of it (subject to legibility!).  Standard forms are a good start, but should be seen as just that – you still need to make sure that they are appropriate for the particular issue in question and that you fill them out properly.

14. Nothing is going to remove all potential disappointments for clients and veterinarians when veterinary outcomes do not go according to plan and a good paper trail will not prevent complaints being made.  However, what it will do is assist in responding to such complaints and in defending them.  Furthermore, a paper trail should facilitate good communications with clients, such that the prospect of misunderstanding is reduced thereby decreasing the prospect of complaints being made in the first place.

15. For further information on maintaining a good paper trail and other ways to reduce your risk as a veterinarian, visit Guild Insurance's Risk Management website, www.riskequip.com.au.

This article was written by David Short of Meridian Lawyers on behalf of Guild Insurance Limited. AFSL No. 233791. This article contains information of a general nature only and is not intended to constitute the provision of legal advice.