Clinical notes

Re: Clinical notes

karen jones — Thu, 26 Mar 2015 13:35:52 GMT

This thread has made me think and I've asked. our assistants to think of a way of recording this data in a fast manner without interfering too much with how we work. Will contact our pms to ask if they do an app or someway of entering data while out and about .

Re: Clinical notes

Braden Collins — Wed, 25 Mar 2015 05:26:55 GMT

I think our VPM software, Vetlink SQL can do a similar thing, with an ipad app and also off line laptop use.

I think having recorded all this makes perfect sense. How else can someone follow up your work if there are insufficient notes?

As an example, in one job I worked one of our vets did a lambing. The next day we got called back out to deliver the twin. The vet swore he had checked for spares and tears. A few days later, the same thing happened to me with the same farmer. The boss went us both crook and decided he would do the next lambing there. What do you know, same thing happened to him. Unfortunately none of us recorded ear tag numbers, but I don't for a minute believe we all missed twins when we all checked for them. It was a valuable lesson in recording.

Re: Clinical notes

Laurence Webb — Tue, 24 Mar 2015 22:09:50 GMT

Teleos has an IPhone ap for this purpose, although as I do small animals I haven't looked at it. I believe that it can also be downloaded onto a laptop and synchronised on return.

Regarding batch numbers, NVS send out batch number reports monthly for small animals but they can be sent out weekly for large animal use - it will still depend on stock management being efficient to work. I guess it depends if it is less work to use a pen and paper than try to install an automated system.

Re: Clinical notes

Anne Seawright — Tue, 24 Mar 2015 20:36:22 GMT

[quote user="Clive Ansell"]

Do any of the practice management systems have the facility where notes at the farm or stable can be written on a laptop, tablet or similar device which will then sync either automatically or manually with the main system when back at the practice?

Do the ear tags have barcodes that could be scanned?

[/quote] Yes I have used this when locuming at an ambulatory practice, took a laptop with me and did everything offline then synced it when got back to the practice. I can't remember to be honest what PMS system it was, I think it was Rxworks or robovet.

Re: Clinical notes

Clive Ansell — Tue, 24 Mar 2015 17:56:02 GMT

[quote user="Robin Grimmer"]

Dictaphone?

[/quote]

Good idea, then I guess nurses or reception staff type up the notes? voice recognition software even better.

Re: Clinical notes

Robin Grimmer — Tue, 24 Mar 2015 17:47:22 GMT

Dictaphone?

Re: Clinical notes

Alan Tevendale — Tue, 24 Mar 2015 17:39:08 GMT

Our PMS (Evolution) can do this although I've never set it up to run this way. We tend to just write up any clinical notes when we return to the practice. The client is given a duplicate slip that is used to record charges and batch numbers etc.

Re: Clinical notes

Clive Ansell — Tue, 24 Mar 2015 17:12:25 GMT

veterinary profession? 21st Century? Never in 100 years.

Seriously, electronic notes that automatically sync would be quicker and easier. All my emails, contacts and calendar entries written on Blackberry when out and about will sync with my home PC - simples. I signed for a recorded delivery parcel yesterday, the details and signature can be viewed online almost instantly.

Re: Clinical notes

Martin Atkinson — Tue, 24 Mar 2015 17:05:45 GMT

[quote user="Clive Ansell"]

[/quote]Wow. Considering that the OP is griping about writing notes up at all this would be the equivalent of the industrial revolution, dragged screaming and shouting into the 21st century.

Re: Clinical notes

Clive Ansell — Tue, 24 Mar 2015 16:56:42 GMT

Do the ear tags have barcodes that could be scanned?

Re: Clinical notes

bob lehner — Tue, 24 Mar 2015 16:29:24 GMT

VMD Guidance Notes no 14 'Record keeping requirements...' paras 9 &10 spell it out for vet and animal owner:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/364508/PCDOCS-_406748-v3-VMD_VMGN_014_A_-_Record_Keeping_Requirements_for_Veterinary_Medicinal_Products.PDF

Re: Clinical notes

Thomas Johnson — Tue, 24 Mar 2015 15:51:04 GMT

[quote user="An On MRCVS"]

I'm looking for some advice ahead of a meeting with the 'bosses'. The farm department in my practice have been told we have to start recording the eartag of every animal we examine and administer treatment for. Then upon returning to the practice we have to make detailed notes of clinical examinations on the practice computer software. I am aware we have to make such notes for 'off licence' use but do we need to do this for all medications?? I have read the VMD notes for guidance and can't see it as a clear stipulation.

Any thoughts are much appreciated. So are any suggestions as too for the easiest way off accurate batch recordings for dispensed or administerd drugs from the back of the car.

Thanks in advance.

[/quote]

When I started my first job in mixed practice (12 years ago) we used hand written duplicate invoices, and recorded the batch numbers and expiry dates of the drugs we used. One copy would be sent to the farmer with their monthly bill, and the other copy kept for the practice records. I always found it odd that we didn't keep full clinical records for farm animals, and after discussing it with my boss we started using a diary to write up farm visits. I'm now in small animal practice so don't know what they do now.

Re: Clinical notes

Martin Atkinson — Tue, 24 Mar 2015 15:36:45 GMT

[quote user="An On MRCVS"]we have to start recording the eartag of every animal we examine and administer treatment for. Then upon returning to the practice we have to make detailed notes of clinical examinations on the practice computer software. [/quote]Don't know if I'm getting the wrong end of the stick here but isn't this what we've always done in small animal practice whether it be on a computer or written notes.. Forgive me for assuming that farm vets should have to do the same - otherwise how can you maintain a clinical record and chain of responsibility?

Re: Clinical notes

Sammy82 — Tue, 24 Mar 2015 15:32:19 GMT

We had to do this too when I worked in mixed practice. I was told it was a legal requirement to provide the farmer with this information (drug used, batch nr, withdrawal time). This should be done at the time of treatment to make sure the animal doesn't go for slaught bexore the withdrawal time is up. Of course good farmers have their little diary with them and keep a record anyway, but not all are that good at record keeping and might not remmber which one of their 150 black heifers received that jab last week, also some assume a month withdrawal for any antibiotic. We used a reiceipt book, you gave the top sheet to the farmer and kept the other copy for our own record and proof that we told the farmer about the withdrawal. Having clinical records is crucial should it come to a complaint. Especially if a case doesn't go well it is important to make good notes, including advise given, especially if you know/have the feeling that the farmer will not do as told. We had a diary (one page per day) in the car for this purpose. I always(tried to) write down notes before I left the farm. Details already on the sheet given to the farmer could be added later.

This definetely adds 5-10min to every farm visit as you always end with standing at the boot and picking out all the bottls acain to note the batch numbers. Although you will quickly know the batch numbers of your most used drugs, they don't change too often. You usually know as well if you used the same bottle as yesterday and can just copy the numbef from yesterdays page. A good inventory list of your car can also help to save time but obviously needs to be kept up to date. I often carried a liitle notebock in my pocket to write down eartag numbers, or I used my phone to take a photo of the ear tag out in the field.

Re: Clinical notes

Emily Rainbow — Tue, 24 Mar 2015 14:47:49 GMT

I have a duplicate pad in the boot of the car so as I put my drug bottles away I can note batch numbers and expiry dates, a copy goes to the farmer and the other I then take into the practice to use as I write up my visits, then gets shredded once done.