• Written by VETport

Records get attention twice: when a client asks for a copy, and when something has gone wrong. Both are bad times to discover that the note is thin, the consent is on somebody phone, or nobody knows how long the practice keeps things. This is what a defensible record looks like and how to make yours one.

One caveat first. Retention periods and access rights are set by your own state, province or country, and they vary more than people expect. Nothing here replaces checking your own regulator.

What belongs in the record

The working test is whether another clinician could pick up the case from your note alone. That means the history you were given, what you found, what you concluded, what you recommended, what the client agreed to, and what was actually done, including doses and batch numbers where relevant.

The SOAP format exists to make that structure automatic rather than something to remember at the end of a long day, which is most of why it has lasted.

The parts most often missing are the ones that matter most when a record is examined: what was recommended and declined, and what the client was told about the risks. A note saying the owner declined dental radiographs after the risks were explained is worth more than three paragraphs about the procedure that did happen.

How long to keep it

Retention for veterinary medical records is set locally and commonly runs to several years past the last visit, with longer requirements for controlled drug records and, in some places, for animals owned by minors. Rabies and other statutory vaccination records often have their own rules.

The practical advice is to find your own requirement, write it down where the practice can see it, and then keep records longer than the minimum. Digital storage is cheap and the cost of not having a record when you need one is not.

Who can see it

The record generally belongs to the practice, while the information in it belongs to the client. A client asking for their animal history should get it, promptly and without it becoming a negotiation. Refusing looks like something to hide, and in most jurisdictions is not defensible anyway.

Where it gets less obvious is transfers to another practice, insurers asking for history, and the second owner of a rehomed animal. Have a position on each of those before you are asked. Giving clients direct access to their own records removes most of these requests entirely, which is worth considering on workload grounds alone.

What about texts, emails and photographs?

If it contains clinical information or records a decision, treat it as part of the record. A consent given by text message is a consent. A photograph an owner sent of a wound is a clinical observation. A recommendation made by email is a recommendation.

This is the strongest practical argument for client communication living inside the practice system rather than on individual phones and personal inboxes. A message thread that exists only on a nurse phone is not in the record, is not searchable, and leaves with the nurse.

Access, audit and who changed what

Two things worth checking in your own system. Whether you can tell who wrote or amended an entry and when, and whether staff access is limited to what each role needs.

Amendment history matters because a record that can be silently changed is worth less when it is examined. Role based access matters because the alternative, everyone can see everything, is difficult to justify and easy to fix. Our piece on data security for veterinary clinics covers the wider version.

The five minute audit

Pull three records at random from last month. Can another clinician follow the case. Is what was declined written down as well as what was done. Is the consent in the record or in somebody memory. Can you see who wrote each entry. And do you know, without looking it up, how long you are required to keep it.

Most practices fail at least two of those, and all five are fixable inside a month.