Writing Skills for Veterinarians

Ryane Englar

• Publisher: 5m Books
• Year: 2019
• ISBN:
  9781789180534
• Topic: Medicine
• Subtopic: Veterinary Medicine

Communicating ideas in veterinary medicine is a fundamental part of continuing veterinary research and building a career as a clinician.The purpose of this book is to help increasing efficiency and effectiveness in writing professional documents, e.g. writing a concise yet thorough discharge statement to avoid repeated client call-backs to clarify medical recommendations. The book also aims at improving the reader's confidence in writing skills through guided and well-thought out "homework" or practice exercises.Useful for both veterinary students and practising vets, Writing Skills for Veterinarians addresses how to develop and hone veterinary medical and scientific writing techniques. The basics of veterinary writing and why it matters are covered before concentrating on specific written models expected of vets – creating medical documents, client and colleague communications, report writing, journal articles and research papers and presentations. At the end of the book is a resource-bank of additional exercises relating to each type of document.

Chapter 1
Introduction to Medical Documentation

We rely on documentation in everyday life. Purchases, large or small, are documented by receipts. International travel requires proper documentation to gain entry to other countries, and legal documentation is necessary to officiate a wedding, execute a living will, or grant power of attorney. Just as documents are a way for us to navigate personal circumstances, they also serve as a means by which colleagues communicate within a profession.

How a profession speaks through writing varies depending upon the discipline. For example, those who author English language or comparative literature manuscripts follow the Modern Language Association (MLA) style.(1) Likewise, medical disciplines adhere to their own set of rules when documenting provider–provider or provider–patient dialogue.(2–5) The profession of veterinary medicine shares this common need to communicate what constitutes patient care and how care for any given patient evolves.(6)

Learning how to communicate in writing as a clinician takes practice and attention to detail. Medical documentation may be tedious, yet it is no different than any other skill: it is capable of being learned and refined.(7)

As a veterinary student, I disconnected myself from viewing the medical record as a skill. To me, clinical skills were tangibly linked to patient outcomes: clinical skills were synonymous with clinical procedures – they were about doing something actively rather than passively writing. I dreamed of the day when I would perform surgery or dentistry. I never once dreamed of the day when I would make an entry into a veterinary medical record. However, medical documentation is just as important as drawing blood or taking a radiograph. It may not be exciting in the moment, but proper documentation is the vehicle by which we as clinicians guarantee that quality care was offered, accepted, and received.(8)

1.1 The “So What?” Factor: Why Medical Documentation Matters

If students view medical documentation as just another academic exercise, then it will always be an afterthought. Educators may unconsciously perpetuate this message by teaching it “on the fly” during clinical rotations, where patient care and record-keeping overlap. However, if educators can present medical documentation as an essential clinical tool that stimulates critical thinking, then students are more likely to recognize its value. Understanding how effective medical documentation contributes to case management is an important first step towards strengthening the profession’s commitment to being thorough and complete.

In veterinary medicine, documentation matters most to the following entities:

• The patient
• The client
• The veterinarian
• The veterinary team
• The scientific community
• The law.

From both the patient and client perspective, documentation matters because it is a written record of the care that was received.(8) It can also be referenced when considering how patient care should proceed. For example, after a hospitalized patient is discharged from the clinic, the client may telephone to clarify when the next dose of medication “x” is due. This question is easily addressed by referring back to the patient’s medical record. Complete documentation will include medication “x,” its dose, dosing frequency, dosing route, and the time that it was last administered. In this case, documentation promotes compliance and minimizes the risk of accidental under- or overdosing.

From the veterinarian’s perspective, documentation matters because it is a way to work through each clinical case, justify decision-making, record diagnostic and therapeutic interventions, and make adjustments to care based upon patient response to treatment.(9) For example, suppose a patient is admitted to the hospital for observation following a one-time episode of vomiting. The clinician will mull over the history and physical examination findings to determine which diagnoses are most likely and will advise the client accordingly. The clinician will keep track of certain vital parameters based upon an index of suspicion and will document trends. As the patient’s clinical presentation evolves, so, too, does the clinician’s plan of attack. What was once considered as a differential diagnosis may be ruled in or ruled out depending upon the patient’s progress or diagnostic test results. Documentation thereby serves a purpose: a way to foster critical thinking about case patterns and decision-making.

Documentation is also a way for veterinarians to protect against faulty memory – theirs or the client’s. Consider a recently adopted, indoor/outdoor, 12-week-old, female spayed, domestic shorthaired kitten that is new to the practice. History reveals that the kitten is acclimating into a multi-cat household, eating and drinking well, and using the litter box without issue. However, physical examination reveals epiphora and an isolated sneeze.

The veterinarian alerts the client that upper respiratory infections are common in kittens and that the stress of transitioning to a new household is often an inciting factor. The client is told to watch for a runny nose, lethargy, and inappetence because these could be signs that an infection has taken hold. In addition, the veterinarian reviews proper nutrition, vaccination protocols, and serological status with the client, and makes recommendations for topical flea preventative, fecal analysis, and microchipping. The client agrees to drop off a stool sample, but fails to follow through.

Three weeks later, the client contacts the clinic because spaghetti-like worms are in the litter box and she is frustrated: “No one told me that my Ginger could have worms!”

If I were the clinician in this case, I would not recall with certainty what transpired three weeks ago. I would assume that gastrointestinal parasites were discussed, but there is no place for assumptions when it comes to patient care or customer service in the healthcare industry.

In this case, documentation provides instant recall. A cursory review of the medical record outlines that yes, in fact, the possibility of gastrointestinal parasites was discussed with the client and that yes, in fact, she was encouraged to hand-deliver a stool sample and administer prophylactic dewormer.

The clinician could then follow up to clarify if dewormer was administered or, if not, why? Is there a patient compliance issue? If so, it is important to establish this early on so that strategies for administering medication can be discussed before additional doses are missed. In this way, documentation serves as a record of client education: what was discussed with the client and what the client did or did not agree to.(7)

From the perspective of the veterinary team, documentation provides for continuity of care within a practice. For example, colleagues frequently inherit other clinicians’ cases when they call out sick, are attending a conference, or are away on vacation. These cases do not run themselves in the absence of the original attending clinician. Transferring patient care to a clinician who has access to a complete medical record is advantageous. Record review should uncover the rationale for ongoing treatments as well as outline which parameters are being assessed to evaluate patient status. By reviewing the record and tracking the patient care plan, diagnostic tests are not unnecessarily repeated and the client is kept in the loop regarding diagnostic test results.

Documentation also assists with recheck appointments that, for various reasons, are not scheduled with the veterinarian that made the initial diagnosis. Consider the colleague who has inherited a recheck appointment for chronic dermatitis. This veterinarian may have little to no relationship with the patient or client, and little to no firsthand knowledge of what transpired at the initial consultation. A complete medical record provides key insight into how the patient presented, in order for the veterinarian to make educated decisions about whether the patient has improved or regressed.(10)

It is equally important to maintain continuity of care between practices. Second-opinion cases and referrals to board-certified veterinary specialists are common. Both scenarios require facilities to communicate with one another via medical records to demonstrate the flow of care, what has and has not been done to address the presenting complaint, and where to go from here.

If a patient from Practice “A” presents to Practice “B” for a second opinion for chronic diarrhea, documentation from Practice “A” provides Practice “B” with a starting point. The veterinarian at Practice “B” will appreciate that the patient has already submitted to a complete blood count, a serum chemistry panel, a fecal float, and one round of metronidazole therapy that started on day “w,” at dose “x,” at “y” dosing frequency, for “z” number of days.

The secondary provider should receive the results of each test as well as an outline of the patient’s response to treatment. This transparency on paper prevents unnecessary duplication of effort and facilitates decision-making about next steps. Skillful management of cases and consumer satisfaction often stem from the perception of organization and easy-to-retrieve data.(10)

From the perspective of the scientific community, documentation matters because it provides data that fuels the research industry and paves the way for an evidence-based approach to clinical medicine.(10, 11) Consider, for example, Borrelia burgdorferi, the causative agent of Lyme disease. Veterinary medical records and national databases provide information about this emerging disease, its prevalence, and its geographical distribution.(12–14) Much of what is known today about Lyme disease can be traced back to case studies that link the development of antibodies to B. burgdorferi to clinical disease.(15–26) Without documentation to record the clinical presentation and diagnostic work-up, Lyme disease may not have been linked to arthropathy or nephropathy.(15, 19, 21, 23) Without documentation of host responses to B. burgdorferi and without documentation to trace the serological prevalence of the causative agent over time, there may not have been a push for the development of a Lyme vaccination. Vaccinations arise from a need, and evidence to support that need resides in the medical record.

From the perspective of the law, documentation matters because it is a legal record of patient care: what happened, what did not, and why.(8, 11) The medical record exists to protect the patient from substandard care. When the quality of patient care and/or the competence of the attending clinician is called into question, it is the completeness of the medical record that dictates whether the standard of care was met.(8)

Standard of care is not static: it evolves over time as the profession’s knowledge grows. Local, regional, national, and international organizations set guidelines for clinical practice that are in tune with legislation. These guidelines vary from country to country and between continents depending upon legislation, species serviced, and the context of a given clinical scenario. As evidence-based medicine paves the way for scientific discoveries and improved understanding – for example, the need to provide analgesia in addition to anesthesia – guidelines change shape and form. In this way, they are malleable. They may shift based upon changes in cultural and ethical perspectives.

Global organizations that weigh in on veterinary standard of care include, but are not limited to, the:

• Association of Shelter Veterinarians (ASV)
• International Association for Aquatic Animal Medicine (IAAAM)
• International Veterinary Academy of Pain Management (IVAPM)
• World Organisation for Animal Health (OIE)
• World Small Animal Veterinary Association (WSAVA)
• World Veterinary Association (WVA).

Within the United Kingdom (U.K.), both the British Veterinary Association (BVA) and the British Small Animal Veterinary Association (BSAVA) play important roles in setting high standards for clinical practice.

The Animal Welfare Foundation (AWF) was founded by members of the BVA. Both groups work together to address ethical issues, particularly those involving production animal medicine, such as the transport of livestock and animal welfare at time of slaughter.

The Canadian Veterinary Medical Association (CVMA) also helps to define standards within the profession. The CVMA serves as the voice of the Canadian veterinary team. In addition to the CVMA, Canadian veterinarians rely upon regional governing bodies within their individual provinces, such as the Ontario Veterinary Medical Association (OVMA) and the College of Veterinarians of Ontario (CVO).

In the United States (U.S.), key players include, but are not limited to, the:

• American Animal Hospital Association (AAHA)
• American Association of Bovine Practitioners (AABP)
• American Association of Equine Practitioners (AAEP)
• American Association of Feline Practitioners (AAFP)
• American Association of Swine Veterinarians (AASV)
• American Board of Veterinary Practitioners (ABVP)
• American Veterinary Medical Association (AVMA...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• About the Author
• Preface
• Dedication
• Acknowledgments
• CHAPTER 1 INTRODUCTION TO MEDICAL DOCUMENTATION
• CHAPTER 2 LEARNING THE LINGO: THE LANGUAGE OF MEDICAL DOCUMENTATION
• CHAPTER 3 STRUCTURING THE MEDICAL RECORD
• CHAPTER 4 THE “S” IN SOAP NOTES
• CHAPTER 5 THE “O” IN SOAP NOTES
• CHAPTER 6 THE “A” IN SOAP NOTES
• CHAPTER 7 THE “P” IN SOAP NOTES
• CHAPTER 8 COMMON MISTAKES IN SOAP NOTES
• CHAPTER 9 ACADEMIC SOAP NOTES
• CHAPTER 10 VARIATIONS OF SOAP NOTES
• CHAPTER 11 OTHER MEDICAL DOCUMENTS
• CHAPTER 12 AN INTRODUCTION TO SCIENTIFIC WRITING
• CHAPTER 13 DECIDING WHAT TO WRITE
• CHAPTER 14 WRITING THE ORIGINAL RESEARCH ARTICLE
• Appendix 1: Supplemental Exercises to Master Veterinary Medical Jargon
• Appendix 2: Supplemental Exercises to Master the Medical Record
• Appendix 3: Additional Resources That Provide Guidance for Record-Keeping
• Index