RESOURCES SUPPORT RECORD KEEPING
The College continues to focus on its strategic objective to promote professionalism in the
practice of veterinary medicine. This includes providing resources to veterinarians on key areas
that are identified as risks in the practice of veterinary medicine. One of the key areas of focus
is compliance with legislation and professional practice standards for record keeping. The
medical record reflects the quality of care that is delivered to an animal or group of animals.
By Kim Lambert, DVM
Associate Registrar, Quality Practice
To mitigate risks to the public, the College’s
Peer Review of Medical Records (PRMR)
supports veterinarians in meeting the
standards for medical record keeping. In
March 2018, Council formally established
the Peer Review of Medical Records as
a mandatory component of the College’s
Quality Assurance Program.
With direction from the Quality Assurance
Committee, a redevelopment project was
undertaken by the College in 2018 to
strengthen the learning outcomes of the
Peer Review of Medical Records process.
Changes to the PRMR process include a
revised random selection process, measures
for determining a successful assessment,
and re-evaluation of records for practices
that do not achieve a successful result in their
assessment.
Participation is mandatory under section 50
of Ontario Regulation 1093. With the PRMR
process set to resume in March 2019, the
College has numerous resources to assist
veterinarians in ensuring their record keeping
is meeting standards and encourages
veterinarians to review these supports for
good practice. Veterinarians can access a
free online learning module series on medical
record keeping available on the College’s
website.
The College receives comments from
veterinarians related to the amount of
documentation that is required for medical
record keeping. It may be viewed by some
veterinarians as “red-tape” or a burden on
their already busy practices where their
focus is on delivering quality patient care. It is
understandable that some see medical record
keeping in this way. When veterinarians are
Winter 2018
Vol. 34 No. 4
ISSN 2370-5965
FEATURED
A spotlight on policy
This issue of College Connection explores
the College’s policy initiatives. The College
welcomes your feedback on College
Connection.
trying to balance the demands of their
workload and the importance of self-care
and wellbeing, anything viewed as tipping the
balance toward a higher workload can seem
arduous.
While it is a veterinarian’s obligation to comply
with the rules for record keeping, the purpose
and rationale for record keeping goes beyond
just rule-following. The medical record is a key
component of a veterinarian’s duty to patient
care.
The basis for complete medical records is
for the provision of care to the patient. The
most important reason to document patient
care is for the patient. It ensures the continuity
of care to the patient, which facilitates the
delivery of quality care.
continued on page 2
CONTENTS
Executive Committee . . . . . . . . . . . . . . . . . . 2 Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Learning in Practice . . . . . . . . . . . . . . . . . . . 6
Members’ Forum . . . . . . . . . . . . . . . . . . . . . . 3 Annual Report 2018 . . . . . . . . . . . . . . . . . . . 5 Antimicrobial Stewardship . . . . . . . . . . . . . . 7
Instilling public confidence in veterinary regulation.
www.cvo.org