Regarding Medical Records

Simply put, a medical record is the set of notes that a veterinary facility keeps for each patient. Many pet owners confuse their receipts with medical records. Other times, the pet owner assumes that they can verbally summarize the medical records when asked. However, the medical record is much more detailed. It should include obvious items such as any laboratory results that your pet has had done, including specific blood values, and often times includes less obvious items, such as the location of where a particular vaccine was given, or the changes in your pet's weight.

Because they provide crucial medical information on your companion, attending veterinarians will usually want to review these records as part of a thorough exam. This is especially true if the veterinarian is unfamiliar with the patient, as when a different doctor is in the office seeing your pet, or when you are visiting a new clinic for the first time.

























Excluding medical services such as radiographs (x-rays) and ultrasounds, most medical records are in the form of handwritten notes that the attending veterinarian and his or her staff accumulate in the course of providing medical care to your loved one. Sometimes, a medical record may consist of electronic/typed notes. Finally, many medical software packages allow the user to readily produce "patient chart" printouts that summarize visits but do not convey the information that is in the medical record. Here frequently occurs a problem for the pet owner. When you are seeing a new veterinarian and request your pet's medical records so that the new veterinarian can review them, some animal clinics will provide the incomplete patient chart summary - an electronic printout that is of little use to the new physician. In short, it's like asking for a photo of your child, and getting a silhouetted drawing instead.

The quandary may be easier to describe in more familiar terms. Consider your own medical care. You may have office visit receipts for copayments, or insurance forms that describe what was done and what was paid for by the insurance. You may even have a letter from your own doctor that states your last lab results as "normal." These are often similar to the information provided by patient chart summaries. In contrast, a medical record is the actual patient chart that your doctor possesses. It is the chart that you may see the doctor walk-in with, or that you may see the nurse inputting into a computerized records system. It is your record that records everything from medications prescribed (including WHY they were prescribed), to the temperature reading that is probably measured every time you walk into the office.

Consider the images in this blog post. (For privacy we've deleted sensitive patient information). Can you guess which one is the medical record, the receipt, and the "patient chart summary?" Can you see details in the medical record that are not included in the summary or in the receipt?

Knowing about medical records helps you provide better care for your loved one in several ways. Because of the time and effort that goes into compiling them, as well as the information conveyed in thorough medical records, they are a critical, valuable asset of your companion's care - they are part of what you pay for when you visit your veterinarian. Several lessons can be learned here. For one, we strongly urge you that when you visit a new veterinarian, you contact your previous veterinarian and request that they forward medical records to your new veterinarian. Second, we encourage you to ask your current veterinarian what her or his medical records policy is. If your veterinarian has the best interests of your companion in mind, they should provide all detailed records without hesitation, as they are necessary and essential to providing your companion with the best possible medical care. Finally, when seeking a new veterinarian, see if he or she requests that you obtain your pet's past medical records. This is always an encouraging sign that your new companion is being seen by a more thorough veterinarian.

Finally, it should be mentioned that by California law, medical records must be maintained for 3 years from the date of last visit. After that, the veterinarian may dispose of them.

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