After a Shift Ends, the Paperwork Begins

Emergency veterinarians at most hospitals work a 12-hour shift, give or take a few hours. That time is generally all spent seeing patients, managing in-patients, doing procedures, or working on other doctor-y things, like returning phone calls, calling about patient test results, updating clients about hospitalized pets, or writing hospital discharge instructions.

Once all of the urgent patient care is complete and the doctor is done for the day, there still looms a pile of paperwork to do. For every patient that the doctor sees, medical notes have to entered, either as hand-written notes, or in an electronic medical record system (EMR).

My stack of notes from the past week. All the scribbled shorthand must be transcribed into something readable.

Fortunately, my practice uses EMRs, so I am saved from the ongoing hand cramps of my early career. But that still leaves a lot of work left to do. If I see 15 patients in one shift and each EMR takes 10 minutes to write, that leaves me with 150 minutes, or 2 and a half hours of additional work. For cases that required more complicated discussions, abnormal test results, or any procedures, that chart will take longer than 10 minutes.

For a doctor in general practice, many of the appointments will be for routine preventative care. That’s vaccines, flea and tick prevention, wellness bloodwork, etc. So when most of your patients are going to be normal and need a predictable set of items completed, you can work more from a template and just delete items that don’t apply. These records are easier to write. But in emergency medicine, these types of cases are less common.

Writing a thorough medical record is important. It helps to communicate information to the next veterinarian to see the case, whether it’s a pet in the hospital or the local vet who does the follow-up care.

Your records will also save your butt if you ever have to face a board complaint or lawsuit. I have had one board complaint brought against me in my career and it was thrown out after initial review. My attorney complimented my records and told me he didn’t think there’d be any problem, and he was right. The police report filed against the client probably helped as well (but that’s a story for another day).

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