Case handover guidance
The Board frequently sees complaints involving issues relating to handover between veterinary practitioners in multi-vet practices where patients have been hospitalised for a period of time.
Often in such cases, multiple veterinary practitioners have been involved in the care of the animal. Board investigations of such matters generally involve all veterinary practitioners who engaged in the care.
Keep good records
While the Board’s Guidelines are currently under review, the revised Guidelines are likely to contain a statement along the following lines, 'A veterinary practitioner must ensure that veterinary records contain sufficient information to clearly identify the animal(s), justify their clinical management and treatment, and allow another veterinary practitioner to continue care if needed." [VPRBV Note: similar information was included in Guideline 7.1 effective from May 2021.]
The clinical record should include any relevant interpretation of changes in an animal’s condition and any revisions to the treatment plan.
A clinical record should stand alone, so the next rostered veterinary practitioner can continue the care of the animal.
Importantly, the clinical record should clearly identify the practitioner who made the entry.
In a number of recent complaints to the Board, important clinical information was only written on ‘cage cards’ that were not retained by the clinic, making it very difficult for the practitioner to provide supporting evidence of the care given to the animal. It is good practice to ensure that any key information on cage cards is also included in the clinical record.
Handover during rounds
Ideally, when veterinary practitioners complete a shift there should be a verbal handover (or “rounds”) of animals in ongoing care. Verbal updates should summarise the information that will also be documented in more detail in the clinical record. If a practitioner is unable to undertake a verbal clinical handover, the clinical record should convey all salient information.
Client communication
Complaints also arise when owners receive differing advice from different veterinary practitioners, particularly when there is a change in treatment plans or prognosis.
Handover notes should include details of communication with the client, so the next practitioner is made aware of any update provided, including whether additional treatments were discussed with the client and any necessary further consent was obtained from them.
Relevant guidelines