by Gigi McWhirter
Whether you take your animal into a veterinary practice for an annual vaccine visit, an emergency or a sick patient examination, a patient record will either need to be created or updated as part of the comprehensive medical history. Why is the chart so important?
Just like in human medicine, a chart is created to provide a written record of your pet’s medical history. It’s “history” begins the moment you cross the threshold of the doctor’s office and stays with that animal throughout the entire relationship you or the animal has with that particular practice. Procedures, discussions, medications, diagnostics and laboratory results are kept in that record, so the veterinary staff can use it as a reference for medical care.
Your pet’s record could look something like this:
Animal Name: “Valentina”
Breed: Labrador/Poodle Mix
Gender: Spayed Female
Date of Birth: 2.14.17
Owner contact information – including your name(s), phone numbers, mailing and email addresses are also logged.
Other pertinent information such as prior medical history, allergies, whether they are indoor or outdoor pets, microchip number, and behavioral notes – like “CAUTION, WILL BITE” will also be recorded.
At each visit, the reason the patient is being seen will be noted when you first arrive.
Once you are called to go to the exam room, the conversation for care will begin and be noted. The doctors will use that information to begin the treatment process. The doctor will log diagnostics and treatments recommended and/or used at that visit.
The chart is also used as a line item record of billable procedures. Just like the business you own or work for, payment is necessary to keep the office open, so they can continue to care for your beloved pets.
The original chart is a legal document and is the property of the practice. They can be either handwritten or computerized. You, as the pet owner can request copies – but again, the original belongs to the doctor’s office. In Arizona, the length of time legally required to keep a written record is three years – even after an animal has passed. If you are a seasonal visitor, you may want to keep copies of the records with you. You may also want to have copies of your records sent to your vet back home to keep continuity of care. In nonemergency situations, please allow enough time for the staff to prepare and/or send your records to another veterinary office.
Keep your pet’s records with the same attention you do your own. As always, if you have questions about their care, discuss them with your vet, not Dr. Google.
Happy tails to you!