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The Veterinarian-Client-Patient Relationship
As you may know, transcriptionists are needed for a multitude of businesses. With on-going health care reform in the news every day, it is easy to concentrate and keep up with the latest news in the Medical profession. As a business owner, I like to stay current with all business disciplines that we serve and when I was asked the other day, "Why would a Veterinarian need a Transcriptionist?" I thought it might be a good time to share some information.
Veterinary medicine is a medical science concerned with the prevention, diagnosis and treatment of diseases in animals. Veterinary Science is vital to the study and protection of animal production practices, herd health and monitoring the spread of disease. It requires the acquisition and application of scientific knowledge in multiple disciplines and uses technical skills directed at disease prevention in both domestic and wild animals. Veterinary Science helps safeguard human health through the careful monitoring of livestock, companion animal and wildlife health.
As a "companion animal" owner, I know first-hand how important standards and practices are in the Animal-Medical community and appreciate my own veterinarian and the care given to my animals. As a transcriptionist, I appreciate the accuracy necessary in ANY documentation and certainly with regard to medical care - of humans and animals.
Here is some information about why medical records are important for veterinary science.
This medical discipline has been guided by the American Veterinary Medical Association Code of Ethics since 1867. (http://www.avma.org) The Veterinarian-Client-Patient Relationship (VCPR) is the basis for interaction among veterinarians, their clients and their patients. A veterinarian must.
Given the number of animal veterinary interactions that occur on a daily basis, and given the reality that not all these interactions have a successful out-come, the possibility of lawsuits is always present. Over 2,000 cases alleging veterinary malpractice are filed in US Courts annually. The financial consequences of these lawsuits are becoming more expensive for veterinarians and their insurance companies. Malpractice as a standard of legal liability applies only to professionals and veterinarians are accepted as one of those categories subject to this standard of care. Veterinarians need to be mindful of the potential need to prove the management of care in documented medical records.
- Assume responsibility for making clinical judgments regarding the health of the animal
- Have sufficient knowledge of the animal to initiate at least a general diagnosis of the medical condition
- Be readily available for follow up evaluation in the event of adverse reaction to treatment
If all three of these criteria are met, a VCPR exists. When a VCPR exists, veterinarians must maintain medical records. According to the AVMA, there are several stipulations about these records:
- Veterinary Medical Records are an integral part of Veterinary Care. The records must comply with the standards established by State and Federal Law.
- Medical Records are the property of the practice and practice owner. The original records must be retained by the practice for the period required by the state.
- Ethically the information within the Veterinary Medical Records is considered privileged and confidential. It must not be released except by court order or consent of the owner of the patient.
- Veterinarians are obligated to provide copies or summaries of medical records when requested by the client. Veterinarians should secure a written release to document that request.
- Without the express permission of the practice owner it is unethical for a veterinarian to remove, copy, or use the medical records or any part of any record.
Just as I have cautioned human health care providers in the past, I offer the same advice to animal Health Care Providers - please weigh your documentation options and results carefully - for the benefit of all concerned. At Transcription Plus, LLC we take our business and each assignment very seriously and all of us know that accuracy is extremely important. We are particularly mindful that our accurate transcription is very important to individuals - and animals - we've never met whose well-being you have entrusted into our professional services.
Thanks for being a part of the Transcription Plus, LLC community!
Mary Goehring
Ps - and a VERY special thank you from my cats! |
