In the June, 2012 Veterinary Economics there is an item entitled "Bite the bullet and go paperless".
The response to the question regarding paperless record keeping by Dr Jeff Rothstein, prompted this comment. He is quoted as saying that "at our one-year anniversary of being paperless, we no longer pull out the paper chart, except by special request - which almost never happens." And the next sentence reads, "The bottom line: Anything older than a year usually has little bearing on the pet's current health status, Dr. Rothstein says. He indicates that " any chronic or ongoing conditions would be addressed and documented electronically during the transition year." There is always room for disagreement and different approaches to care, but I find these statements to be utter nonsense.
It would be a rare week when I didn't find something of importance in a patient chart that has a major impact on it's current conditions but hasn't come up in the previous year. This week alone, I have found descriptions of drug and vaccine reactions, lick sores following clipping for venipuncture, evidence of incompatibility between client statements of heartworm preventative use and the amount provided, etc. There are all items which may not have triggered "special request", but could have had important impacts on a patient's well being.
I have a very good memory, but I see hundreds of animals. And clients are notorious for their failure to recall events or realize their significance. We keep thorough patient records and organize them so that important items can be quickly seen, and before every appointment I try to review the entire history, so that I am properly prepared.
I don't believe there is any good reason not to have a patient's full history readily available at each appointment, regardless of whether that record is on paper or digital media. Often the doctor doesn't know what information will be important until it is checked.
How often have you personally gone to a doctor and been upset that he or she was unaware of important items in your medical past?
Kenneth M. Kornheiser DVM
Countryside Veterinary Clinic
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