New rule regarding patient record

August 9, 2006

Texas Board of Veterinary Medical Examiners Proposes New Patient Record-Keeping Rule

New rule regarding patient record-keeping proposed by the Texas State Board of Veterinary Medical Examiners would require veterinarians to put in writing an owner's refusal of services.

This would eliminate the egregious "he said/she said" tactics used by some vets to escape accountability without attendant notation in their records.

If you and your pet have ever been the victims of a "he said/she said" scenario, then you know how imperative that this rule be passed.

The proposed rule reads as follows:

Amendment, 573.52, Patient Record Keeping. This amendment adds the requirement that patient records include, where appropriate, an entry noting diagnostics, treatments, or referrals offered by the veterinarian and declined by the owner of the animal.

Finally!

This rule is long overdue and essential in protecting the public from vets who, in order to escape accountability for substandard care, sometimes fabricate scenarios where proper treatments were supposedly offered and then supposedly refused by the owner.

This rule will go a long way in correcting the problems inherent to a "he said/she said" scenario in which vets who are the subject of a complaint can claim they offered services, the owner refused, patients did not receive standard of care, and there is NOT ONE SCRAP OF EVIDENCE THAT ANY RECOMMENDATIONS WERE MADE FOR ANY TYPE OF TREATMENT AT ANY TIME, thereby leaving victims of veterinary negligence and incompetence with nowhere to go when the standard of care has been violated and a vet blames the owner for their own pet's injury or death.

This rule protects both sides -- ethical, competent, conscientious vets will be able to substantiate their statements that proper services were indeed offered and declined; and the others will not be able to use the ABSENCE OF ANY SUCH INFORMATION on a patient record to try to deceive or misrepresent that services were offered in order to shift the blame for violations in the standard of care to the owner.

Inaccurate, incomplete, and unprofessional patient records are key in blame-shifting when standard of care has been breached.

This proposed rule will at least offer some relief to complainants when they are faced with a vet who misrepresents to investigators and others about services and treatments that were "refused."

If vets are going to claim that services or treatments were declined -- and patients suffered as a result of their owners "refusing" proper treatment -- then they are going to have to document it on the patient record that that in fact occurred. No more blaming the owner after the fact while enjoying protection by not having to note such a "refusal" on the record.

This rule will be especially beneficial in the worst cases, where vets who repeatedly omit patient/owner information over an extended period of time, allowing them to continue a pattern of substandard treatment that compromises public and patient health and safety, will no longer be allowed to use this particular method of escaping accountability when they are caught. -- J.C.

The proposed rule reads as follows:

UPDATE - Amendment defeated. Vets do not have to note when services are offered to the client and declined. This leaves vets free to engage in as much he said/she said as they like, with ZERO ACCOUNTABILITY for what they do to your pet.