How detailed do you get into medical notes regarding client communication?
So I’ve been a VA for about 6–7 years now at a corporate vet hospital, and I’ve worked at a few different locations. At the first hospital I worked at, we had a DVM who was very particular about medical notes. She created a template that eventually became one of the district-wide defaults, so the overall note style is pretty standardized across locations now.
One thing she specifically taught me to do was document important client interactions/conversations in the medical notes too- especially if a client is combative, refuses recommendations, or explicitly says they don’t want to discuss something further (vaccines, parasite prevention, diet, dental care, etc). Basically: cover your ass. If an owner says something significant, I’ll usually tell them “I’ll make a note of that,” and move on.
I’ve never had a client get copies of their records and accuse me of lying or defaming them because everything I write is factual/verbatim. But I did a short stint in pet insurance where records are shared more broadly, and now I’m wondering if I should scale this back a little?
The reason I’ve always documented this stuff is: 1) To protect yourself/the hospital 2)To keep the visit transparent for everyone involved 3) To have a clear history if a client later becomes threatening or claims malpractice
I’m extremely literal/objective in my notes. For example, I had a client today get upset over basic history questions (“What medication does your cat take and why?”). He responded that he was “a senior citizen and not capable of just knowing we should keep track of that,” so I documented that interaction (stating he was a senior citizen and could not keep track of that and that we need to keep track of that) because I don’t want him later claiming we never asked about medications/history, especially considering that cat was getting a steroid shot and is 15.
And this is also a client who previously waited outside after closing to harass an associate in the parking lot- and he still was never fired as a client.
So I guess my question is: how detailed are you guys with medical notes/client interactions? Do you document these kinds of conversations too, or keep it strictly medical?