March 2026
In this VETgirl online veterinary continuing education blog, Dr. Anita Dennison, Medical Team Coach with Blue Heron Veterinary Consulting helps us confront the dreaded part of a veterinary professional’s job – medical records! How can we make it easier and ensure medical records are completed in a timely manner? What tools can we use to make it a less gruesome task? Let’s explore some ideas that might make records easier and your life a little less burdened.

Worried you missed something else by the Blue Heron team? Catch the full series of Blue Heron Consulting’s contributions HERE!

The Story Behind Every Patient: Tips for Mastering Veterinary Medical Records

By Dr. Anita Dennison, Medical Team Coach, Blue Heron Veterinary Consulting

If I were to ask veterinarians and technicians what the most arduous or dreaded part of their job was, the majority of them would likely say ‘medical records.’ Completing medical records at the end of a hard day is the last thing anyone wants to do. They seem daunting, even if the cases were routine. So, how can we make our lives better every day and get medical records done in a timely manner? What tools can we use to make medical records a less gruesome task? Let’s explore some ideas that might make records easier and your life a little less burdened.

Change Your Outlook

Sometimes, just changing how we look at a task can change our mindset and help us to get that task completed. For example, if you have to do your laundry because you have to go to work the next day, that is a lot more taxing than washing your favorite jeans so that you can go to the movies or a party with friends. Completing medical records is definitely not a party. So, what if we changed our mindset to create a medical record that is actually a story about what happened at the clinic that day, and followed that with how we were able to help make an animal’s or a person’s life a little better? Even though every case doesn’t have a happy ending, being part of that process still helps the story come to a close.

Make it Count

Every good story needs to contain certain elements so that a complete picture is painted for the next reader. We all know and use the traditional SOAP format because this reminds us of the things that need to be documented in the record and helps us organize each part of the visit. I have heard it said many times to treat each case as if the client is going to go to a specialist for a second opinion. It is easy for us to go through each day treating cases and to become complacent in documenting the details. It is not until that case goes to a specialty center or things don’t go as planned that we recognize that maybe our record-keeping wasn’t so great. It’s the old adage that ‘if you didn’t write it down, it didn’t happen.’

Set the standard

All of us hope to be able to practice gold-standard care in our practice. Our medical records should reflect that. They should also document when a client declines that level of care. This shows that you are at least offering the best medical care for their pet.

Set the Story Straight

The last thing each story needs is a bad ending, where the hero loses. So, make sure the story you are writing covers those things that could land you in hot water. For example, make sure all medications, doses, and frequencies are double-checked. More prudent is making sure that any controlled substances are recorded appropriately in the medical record, in your controlled substance logbooks, and in your electronic practice management software. Not only will this keep you out of trouble with your inventory manager, but it will also keep you out of trouble with the DEA.

Passing Down the Story

Make sure your medical record story can be retold to others. Many of our clients move or travel. It is important that each animal’s story be able to be retold to one of your colleagues so they can continue the care that you started. As veterinarians, we all use mnemonics to help us remember long lists of things like the 12 cranial nerves, for example. So, how about one to help us remember what our medical record story should look like to ensure they can be passed down to others?

Use Available Resources

Trying to do everything by yourself isn’t going to work. Your staff are a fantastic resource. They are there with you as the story unfolds. Make sure they are trained in documentation standards for your hospital and that they have a good walk-around knowledge of medical terminology and medical abbreviations. Your staff are a wonderful resource, are part of your practice, and are part of the story you are all writing together. Use some time in staff meetings to dissect medical records and also praise those records that are completed well.

Work with your practice manager to create templates, bundles, or groups within your practice management software to lessen the time it takes to create estimates and treatment plans, write surgical notes, and create discharge plans.

Use an in-person scribe or AI. Using a scribe, whether it be in-person or an AI assistant, is an invaluable resource. Not only will these help you remember each case individually and minimize mistakes, but a scribe also significantly decreases the amount of time you are using to complete medical records. This extra time can be used seeing more cases during the day or could give you the time to go to the gym, go to your kid’s ballet performance, or just be able to relax before the next shift.

The Final Chapter

Accurate and complete medical records tell the medical story of what you do every day to better the lives of your clients and their animal friends. They help us to pen our thoughts and actions for each case that we see. In the end, this helps us be better veterinarians because we can look at where we’ve been, analyze our thought processes, and use that to grow in our knowledge and service to others.

Blue Heron Consulting is the nation’s leading veterinary consulting team. With a mission to improve the lives of veterinary professionals, they provide veterinary-specific solutions to practice owners, veterinarians, managers, industry leaders, and their teams. At their core is an experienced team that works to amplify strengths, elevate care, remove workflow gaps, create a culture of leadership, and promote sustainable profitability – all while keeping your definition of success at the center of everything they do. To learn more or schedule a conversation, visit www.bhcteam.com.

Please note that the opinions in this blog are expressed by the contributor and not directly endorsed by VETgirl.

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