Friday, June 29, 2007

The Importance of Medical Records

The Importance of Medical Records

When a doctor of any kind is trying to make a diagnosis – determine the underlying disease so it can be treated aggressively and correctly –they have to be a detective. Like a detective each piece of evidence is critical to solving the crime or in our case making an accurate diagnosis. One key piece of information that is often overlooked is the medical history. Now when I say medical history I am not talking about invoices. Over the years when asked by the pet owner for the medical history they often hand the receptionist invoices of visits to previous veterinary hospitals. These list things the owner was charged for and give minimal information. When I say medical records I am talking about what was written in the pets chart by the receptionist, technician, and doctors. It would include history given by the owner, vaccination history, all laboratory results, treatments given, physical exam findings, differential diagnosis, treatment sheets during hospitalization , x rays taken etc. Often times the diagnosis is actually made by reading the records and getting a good history rather than the physical exam findings.
It’s sad to say but some veterinary hospitals are reluctant to give out this information. There are multiple reasons for this including illegible records, (can’t read the doctors handwriting), incomplete records, missing records or even doctors who withhold records because the owner is going elsewhere for a second opinion.
I own an emergency hospital in Avon, Ct and we cover when the owners regular vet is closed. In some cases the pet is being treated for cancer with chemotherapy or other serious diseases. When the referring vet is available after hours to give us the medical history we can treat the pet quickly appropriately often saving its life. When medical records and history are not available our ability to treat quickly and correctly drops dramatically even to the loss of the pet. There is hope however and that is with a visionary website. With this website a pet owner can have their pet’s records current and available. When the need arises the veterinarian treating the pet can quickly access the records and have this crucial information. Technology is wonderful when used appropriately and this is one of those times. I applaud the visionaries who started this concept and encourage all pet owners to utilize the service. It could save your pets life!
Dr. Robb


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