There are two truths about veterinary medicine:
1. There’s never enough time in a day.
2. If it isn’t in the medical record, it didn’t happen.
Given ongoing veterinary workforce shortages and trends toward increased spending on medical care for pets, it’s no surprise that practices are increasingly seeking ways to get more work done within a shorter time period. Efficiency is the name of the game, as we increasingly seek ways to streamline our workflows and reduce wasted effort.
What’s one topic that often keeps veterinarians at work, long after the other hospital employees have gone home? Medical records. And, while it may be tempting to improve your efficiency by cutting corners on your medical records, this is a dangerous approach. Instead, think about ways to create a thorough medical record more efficiently.
Client education templates can help you create thorough medical records in less time, increasing your overall efficiency.
What information belongs in a medical record?
Hopefully, your current medical records are comprehensive, well-organized, and easily understood by any client, regulatory body, or attorney that may request to see them.
If you need a refresher, here’s what your medical records should include:
- Client and patient name
- Date of service
- Presenting complaint
- Patient history
- Physical exam findings, including weight, temperature, pulse, and respiration
- Diagnosis or differential diagnoses
- Services or treatments provided
- List of any services/treatments that the client declined
- Client education that was provided
Many veterinarians use a SOAP format for their medical records:
- Subjective – presenting complaint, patient history
- Objective – physical exam findings (including temperature, pulse, respiration)
- Assessment – strong>diagnosis or differential diagnoses
- Plan – recommended/provided services and treatments (including client communication)
This format provides a simple way to organize your thoughts, as long as you remember to include all necessary details under each category. While most of us are pretty good at documenting exam findings, client communication (including declined treatments and services) may be glossed over in many medical records. This can present big problems, because communication lies at the heart of approximately 80% of cases of alleged veterinary negligence. It’s important to document all client communication thoroughly, in case a question or issue arises.
Templates as a tool for efficiency
Templates can provide a huge boost to record-keeping efficiency. With the right templates, you can add valuable information to a medical record with just a few clicks of a button.
Many practices use physical exam templates, but templates can also play a valuable role in helping you quickly document client education. Templates can also serve as a helpful reminder, ensuring that all important information is conveyed to the client during a particular type of patient visit.
Client education templates can even serve as discharge instructions. Depending on your practice management software, you likely have the option to print some or all of a patient’s record to send home with the client. Client communication notes can act as a simple client handout, helping the client remember information that was discussed during their visit.
Examples of client education templates
To be beneficial, client education templates must be personalized. You wouldn’t make the same recommendations to the owner of a 6-week-old puppy as you would to the owner of a geriatric cat with hyperthyroidism, so these two situations require different client education templates. At the same time, however, it isn’t practical to create a new client education template for every single type of patient you could see in your hospital.
⭐ Consider your most frequent types of patient visits, and focus on creating those templates first.
Wellness visit templates
Wellness visits are a great place to start. Depending on your practice, you probably see six types of wellness visits:
- Puppy visit
- Kitten visit
- Adult dog wellness visit
- Adult cat wellness visit
- Senior dog wellness visit
- Senior cat wellness visit
For each type of visit, create a unique client education template covering everything you typically discuss at that sort of appointment. For example, your client education template for a new puppy visit might include your go-to recommendations on the following topics:
- Vaccine schedule
- Spay/neuter benefits and timing
- Vaccine side effects
- Signs of a vaccine reaction and how to respond
- Flea and heartworm prevention
- Housebreaking, training, and socialization
- Infectious disease risks
- When to return for next appointment
Remember, you can make necessary changes to suit each individual patient. For example, your template may have a blank space where you fill a specific parasite preventative recommendation. However, the text surrounding that product name will likely be the same for every patient and your other instructions may be consistent for all patients of a particular age/species.
Common illness templates
After creating client education templates for wellness visits, think about common illness visits that lend themselves to consistent explanations. (For example, as a new grad, I had a well-rehearsed colitis talk down pat within my first week of practice!) Create a client education template for common sick visits, instructing clients on medications, other aspects of at-home care, and when they should call the veterinary hospital for a recheck. Consider starting with the following conditions:
- Otitis externa
Anything you see with some regularity can benefit from a client education template. Remember, you can always customize these for each individual patient, but having generic recommendations already typed into the practice management system can help you save significant time on record-keeping.
Client education templates can offer significant time savings in the veterinary setting. Whether these templates are integrated into your practice management software or saved as a document on commonly used workstations in your practice, being able to import a list of common recommendations can decrease the amount of time you spend typing repetitive instructions each and every day.