Medical Records Review and Assessment
The College places a strong emphasis on supporting high quality medical records in its Quality Practice Program. Medical records provide the basis for the continuity of veterinary care. A complete medical record tells the story of the quality of care provided to an animal or group of animals and ensures that care can be resumed seamlessly from one veterinarian to the next, from one visit to the next. To mitigate risks to the public, Peer Review of Medical Records supports veterinarians in meeting the standards for medical record keeping that ensure optimal veterinary care can be continued.
Trained Peer Reviewers assess medical records of practices that are randomly selected to participate in a Peer Review of Medical Records, and for veterinarians or veterinary practices who wish to improve their record keeping by volunteering for peer review.
Peer Review of Medical Records participants gain valuable insights into their record keeping processes. After considering the comments from reviewers, veterinarians have made improvements to their records that result in more efficient use of time for all team members, better communication between staff and with clients, and increased capacity to ensure the continuity of veterinary care.
Assessments of medical records are based on legislative requirements and professional expectations for medical record keeping. To assist veterinarians or veterinary practices with preparing for a peer review, and as a resource to others, the assessment questions are provided:
The Peer Review of Medical Records Assessment Report is confidential and cannot be shared with College committees. Information gathered from Reports will only be shared in aggregate form. In rare cases, serious concerns identified by the Peer Reviewer may be brought to the Registrar for review. This only happens if public safety is a significant concern and only the area(s) of risk or concerns will be brought forward; the Report will not be shared.
Individual veterinarians or veterinary practices may volunteer to participate in a Peer Review of Medical Records. Records submissions from a practice must be submitted by the practice director or be accompanied by the practice director’s permission to participate.
The records package submitted for review includes complete copies of medical records for eight recent cases including relevant components. It is recommended that the selected records include two each of the following case types: acute medical, chronic medical, surgical, and wellness or herd-health.
The following Guidelines for Participation, and Selection and Submission of Medical Records will assist you in understanding the process and preparing your records package for submission:
Once your records package is received by the College, it will be assigned to a trained Peer Reviewer for assessment. The College's aim is to complete the assessment and report within six weeks. You will be provided with a copy of the report when the submitted records are returned to you.
Veterinarians and practice directors interested in participating in a Peer Review of Medical Records are asked to contact Megan Callaway, Principal, Quality Practice, at firstname.lastname@example.org to obtain further instructions and forms to assist with the preparation of your records package for review.
Veterinary practices chosen for a Peer Review of Medical Records are identified through a random selection process. Participation is mandatory under Section 50 of Regulation 1093. Approximately 48 practices per year are randomly selected to participate in a Peer Review of Medical Records. Selected practices will receive a letter and information package including the following guidelines along with other forms to assist in preparing their records package for review.
A self-assessment tool is provided to licensed members for their use in assessing the quality of their own medical records. Use of this tool may be helpful before you participate in a Peer Review of Medical Records or before your facility undergoes an Accreditation Inspection . The self-assessment can be completed by an individual veterinarian or by the entire veterinary team as a group exercise.
Self-Assessment Tool Components: