college connection
LEARNING IN PRACTICE
Members of the veterinary profession have a responsibility to uphold standards to ensure the public has access to safe,
quality veterinary care. When those standards are compromised, the College responds. Every veterinarian can learn from
these situations and publishing the details of complaints received and resolved is intended to support that learning. The
example below is taken from an actual case and is offered as a self-reflection tool to improve practice across the province.
MEMBER GIVEN GUIDANCE ON MEDICAL RECORDS, COMMUNICATIONS
CASE SUMMARY
The member saw a cat for vaccinations
and weight loss. The member could find no
physiological reasons for the weight loss
using a physical examination, blood work
and urinalysis. Later that year, the member
examined the cat again, and repeated the
urinalysis and blood work. His weight had
increased.
A month later, the cat had lost weight and
blood work was repeated. The member
performed a radiographic study and ruled
out gastrointestinal abscess, foreign body
obstruction or neoplasia. Exploratory surgery
was authorized by the client.
During surgery, the member discovered
abnormal tissue and phoned the client with
the prognosis. The client did not want to
euthanize the cat. The member removed
some bowel, performed an anastomosis
to reconnect the bowel, and placed an
esophageal feeding tube. The client was
shown a photograph of the bowel that had
been removed. The cat died a few days later
and the histopathology confirmed malignant
lymphoma. The body was sent for cremation.
Several months later, the client’s account
was sent to a collections agency. The client
filed a complaint with the College and
subsequently declined an offer from the
member to withdraw the complaint in return
for a reduction in the invoice and return of the
ashes.
CASE CONSIDERATIONS
The Complaints Committee panel decided
the nature of the allegations did not warrant
a discipline hearing. The panel had concerns
related to the member’s communications with
the client, the record of communications,
informed consent, and the quality and
completeness of medical records. The
member agreed to participate in a Mutual
Acknowledgement and Undertaking to
improve performance in her practice.
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College Connection
The client’s allegations concerned whether
the member was negligent and inappropriate
in managing the various aspects of the case.
Throughout review of the case, the panel
was unable to dismiss or validate the client’s
allegations due to the incompleteness of the
medical records. The panel was unable to
determine if the member could have secured
a diagnosis without the biopsies. Although
the panel did not categorize the member’s
management of the case as inappropriate,
the panel could not fully evaluate the
member’s management of the case due to
the incomplete nature of the medical records.
The panel’s review of the medical records
found they lacked detail. For example, the
panel was unable to determine how much
intestine or bowel was removed as both the
medical records and the histopathology
report do not indicate ‘how much’ of ‘which
structures’ were involved. The member did
record that abnormal tissue was noted in the
area of the jejunum and ileum – which are
part of the “small intestine” of the cat. But
the member was unable to provide the panel
with the photograph she had shown to the
client after the surgery. As a result, the panel
was unable to determine how the client came
to have the understanding the cat’s large
intestine was removed.
The panel was unable to determine if
sufficient communication was attempted
including a differential diagnosis and options
for diagnostic tests and treatment due to the
lack of completeness of the medical records.
Further, the panel had concerns that informed
client consent was lacking in the member’s
management of the case. The client did not
understand the nature of an exploratory
laparotomy was to open the abdomen to
visualize all organs and take biopsy samples
of abnormal tissues to generate options
for treatment and determine a diagnosis.
Abnormal findings can result in actions
that resolve or cure the problem, such as
removal of benign tumours, foreign bodies
or correction of organ displacement. It is
the member’s responsibility to ensure the
client understands the procedures, as wel l
as all associated costs. The medical records
did not indicate that informed consent was
achieved.
The panel was frustrated with the lack of
documentation as to when the member may
have advised the client of the invoice. There
was no evidence in the medical record of
attempts to discuss the outstanding invoice
being made prior to the account being sent to
a collection agency.
The panel had signficant concerns with the
written communication from the member
offering to reduce the client’s invoice in
return for the withdrawal of the complaint.
The panel found this action to be extremely
inappropriate. The member attended the
College and received oral advice with regard
to this concern.
To assist the member in addressing the other
concerns presented in the case, the member
completed an undertaking which included a
peer review of the member’s medical records,
completion of a medical records workshop
with staff, and completion of the College’s
informed consent webinar.
Key Considerations
• Medical Records •
A quality record is fundamental to quality
practice. Review the Professional Practice
Standard and Guide on Medical Records
for details on practice expectations.
www.cvo.org/Resources/MedicalRecords-and-Information
• Informed Client Consent •
Review the Professional Practice Standard
and Guide on Informed Client Consent to
assist you in understanding how consent
is demonstrated. Learn more through the
College’s self-study module.
www.cvo.org/Learning-Modules