More on Medical Records

Elias did a great job explaining the importance of medical records. I told him I'd add in my take on medical records. So, without further ado:

1) Classic example is one of allergic reactions to vaccines and drugs. Clients can tell us that Chloe had a "bad" reaction to vaccines last year. But which vaccines? And how bad was the reaction? Hives? Vomiting and diarrhea? Anaphylactic shock? Local swelling at injection site? The information helps determine the best vaccine protocol for Chloe.

2) Weight changes through the years can help raise our suspicion to diseases and endocrine disorders such as hyperthyroidism in cats and hypothyroidism in dogs.

3) Changes in lab work. Oftentimes, it is not a single abnormal lab value that makes the diagnosis in some medical conditions such as kidney or liver disease. It is the trend i.e. an increase or decrease in the values over the years that help us detect an illness, hopefully in time for a successful intervention.

I can go on and on with examples, but the underlying theme is that medical records are health journals for your pets.

Look at it this way. We do wellness screens and senior screens. I'm sure other veterinarians do also. Why? We talk about "establishing baselines" and "early detection." What good are those tests (which are not cheap) if they don't follow your pet as part of his medical history? The values of those tests do not end after the visit at which the tests were done. I am sure those test results were priceless when it was time to document Bandit had normal kidney and liver values a month before he started eating an infamous recalled product.

To discount the values of medical records is to discount the values of those wellness screens and other preventative care.

When you pay the exam and consultation fee, you are paying us for a service. That service includes documenting our exam findings and plans to keep your pets in the best health possible. That is one of the reason why even the most simple procedure (in your eyes) still take some time for us to do. We don't just give a vaccine or express the anal glands (sacs). We weigh your pet, check his temperature (if presented for vaccines), do the treatment, then note in the record information such as where vaccine was given or the fullness of the glands. Location of vaccine is important if a local swelling / reaction develop later -- sometimes years later in cases of vaccine-associated fibrosarcoma.

Saying medical records are not important is like throwing away the information you paid for all these years. Of course, as with most information, medical records follow the GIGO principle. Garbage In, Garbage Out. Hence, not all medical records are useful. But that does not mean we should not strive to get them whenever we welcome a new patient. Complete informative medical records should be the norm, not the exception. But they are in danger of being the exception if we cease to expect them, if we give in to the thought of "why bother, all we're going to get is the useless bare bones patient chart anyway."

As a veterinarian, I view our patients' medical records as reflections of all the services, expertise and care we provided. To disregard the information and values found in medical records is akin to belittling the knowledge and worth of veterinarians. And since veterinary services often come with a price tag, disregarding medical records is wasting money spent.

For all those reasons, we encourage clients to request medical records whenever they anticipate a change in veterinarian(s). We remind clients who are relocating to let us know in advance so we can provide the medical records to the new veterinarian(s).

To say complete medical records are not needed is to do a disservice to all involved --- pets, clients, and veterinarians.