any veterinary medical offices have changed their system of recordkeeping from a handwritten one to an electronic system. Veterinarians frequently raise questions related to an electronic medical records system, seeking to determine whether there are special rules for veterinary medical records kept in this format. Whether a veterinary practice keeps medical records in a hand-written format or in an electronic system, the same rules apply; there are no special rules for electronic records. There are, however, certain guidelines you should follow to ensure that your electronic recordkeeping system will meet the requirements of the State Education Department, and that your records will be admissible in any disciplinary proceeding or court of law. All the requirements for veterinary medical records set forth in the Guidelines for the Practice of Veterinary Medicine continue to apply when you use an electronic system; in fact, the Guidelines specifically say that “the record can be written or computer generated.” If you use an electronic records system, you must still “record all clinical information pertaining to the patient including sufficient information to justify the diagnosis and treatment,” as prescribed in the Guidelines. Specific information that must be included in every veterinary medical record is found in Guideline 5.14 (see www.op.nysed. gov/prof/vetmed/vetpg5.htm). Much of the information required for the medical record (patient information, assessment of
Electronic Veterinary Medical Records patient when presented at the hospital, diagnosis, recommended treatment, daily treatment records when the patient is treated in-house) should be entered directly into the electronic medical records system. Some of this information required for a veterinary medical record is typically be entered by the receptionist (owner’s stated reason for visit), some by the licensed veterinary technician (visual observations of patient), and some by the attending veterinarian; each of those staff members recording information in the patient’s medical record must be able to enter the information directly in the electronic record system, and each of those staff members must have an identifier in the electronic records system that will appear as their “signature” after any entry they make in the record. While it is often easy to see where a hand-written record has been altered, that’s not the case with an electronic record, and an electronic recordkeeping system must have certain features designed to prevent alteration. The Board for Veterinary Medicine has repeatedly expressed concern about electronic medical recordkeeping systems, and has been willing to accept electronic records only if a system has certain security features, such as a “lock-out” that will prevent alteration of the record after it has been created, and an identifier that will show the date and the identification of any individual making alterations or adding additional information to the record after it was first created in the system. Those features
New York State Veterinary Medical Society
are likely to be key to acceptance of veterinary medical records in a disciplinary proceeding, or in court if a veterinarian has been sued in civil court by a client. Other information that is required to be part of the record may originate outside the veterinary hospital, such as results of outside laboratory tests and consultant reports. A veterinary hospital with an electronic records system should ask for that information to be sent to them in electronic format so that it can be transferred directly to the electronic record for that patient. Information received from outside sources in a non-electronic format can be scanned into the record, but the original written copy should be retained. This rule is particularly important to follow in the case of any handwritten correspondence from a client, where the veterinarian is likely to have the only original copy of the document; a copy of it may not be admissible in court, and it could be a key part of a veterinarian’s case if he or she is sued. Medical records must be kept in a manner that will allow them to be accepted by a court or disciplinary panel. Courts have strict rules for the admission of material into evidence; rules of evidence also exist for administrative proceedings, such as professional disciplinary proceedings, but those administrative rules may be slightly more lenient. The general rule for the admission of written material into evidence is that it must be the original document, not a copy; copies may be accepted in limited circumstances where there is a
certification that the copy and the original document have been examined by the maker of the document, who certifies that the copy is a true and accurate copy of the original document. A printed copy of an electronic medical record should be accepted into evidence, provided the record was originally created as an electronic record. If a veterinary practice is converting hand-written records to an electronic system, those original hand-written records must be retained, and must be retained for the same length of time that any medical record for that patient must be kept. Transfer of a hand-written record into an electronic record by scanning is just making a copy, and while it may be sufficient for use within the hospital, the original document is the one that will most likely have to be produced in a disciplinary proceeding or a court, if the record needs to be entered into evidence in a case. The BVM has been known to ask for the original written records created by the veterinarian when there is any question about an electronic record presented to them as part of a disciplinary matter. Electronic medical records can make recordkeeping easier within a veterinary hospital, but there may still be a need to retain some paper records that were originally created on paper, or received by the veterinarian in paper format. While a hospital may convert entirely to electronic format for daily operations, it’s important not to discard paper documents that you may be required to produce in their original format. Barbara Ahern, Esq.